Chairman - Oklahoma Hospital Annual... · 31/10/2012 · The Oklahoma Hospital Annual Report 2011...

October 31, 2012 To Healthcare Partners and the Citizens of Oklahoma, Quality and availability of healthcare remains an ongoing concern for patients, payers, and policy makers in Oklahoma. Despite numerous initiatives to measure and to improve the quality of care in our state and nationally, variations in quality continue to exist. The following document represents the annual Oklahoma Hospital Report which provides a summary of nationally standardized, hospital-specific quality indicators. This report fulfills a requirement of the Hospital Advisory Council set forth by the Oklahoma Legislature to publish an annual report of hospital-specific quality measures including information on hospital-acquired infections. This report contains two years of complied data in an effort to reduce the timeframe between when data is collected and when it is released. We believe that by providing the information detailed in this report that leaders and public citizens will continue to identify opportunities to improve patient safety and healthcare quality and to make informed decisions when choosing their healthcare provider. Sincerely, Gary W. Mitchell, D.Ph, FACHE Chairman Hospital Advisory Council

(This page left blank)

Oklahoma Hospital Annual Report 2011 Page ii

Oklahoma Hospital Annual Report 2011 Page iii

Table of Content Introduction 1 Services Offered 3 AHRQ Patient Safety Indicators 15

Tier One PSI 4 Death among Surgical Inpatients with Complications 19 PSI 6 Iatrogenic Pneumothorax 22 PSI 11 Postoperative Respiratory Failure 27 PSI 12 Postoperative Pulmonary Embolism or DVT 31

PSI 14 Postoperative Wound Dehiscence 36 PSI 15 Accidental Puncture or Laceration 39 PSI 18 Obstetric Trauma – Vaginal Delivery with Instrument 44 PSI 19 Obstetric Trauma – Vaginal Delivery w/o Instrument 47

Tier 1-B

PSI 2 Death in Low Mortality DRGs 50 PSI 8 Postoperative Hip Fracture 55

National Healthcare Safety Network 59

Central Line Associated Bloodstream Infection 59 Ventilator Associated Pneumonia Events 88

Hospital Compare 107 References 109

Oklahoma Hospital Annual Report 2011 Page iv


Oklahoma Hospital Annual Report 2011 Page 1

Introduction The Oklahoma Hospital Annual Report 2011 is a publication required by 63 O.S., Section 1-707. In an effort to reduce the lapse of time in the release of the data, this report contains two years of the required reportable data. This report is intended to increase the availability of quality data related to hospital services and to improve patient care in Oklahoma. The annual report is an outline of services provided by the Medical Facilities Service of the Oklahoma State Department of Health (OSDH) and displays the hospital-specific quality indicators and healthcare associated infections. There are three sources for the data included in this report:

1. Detailed hospital-specific performance measures outlined by the Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators for care provided during the 2008 and 2009 calendar years. These measures are calculated from the standard hospital discharge data set reported to the OSDH Healthcare Information Division

2. The National Healthcare Safety

Network (NHSN) data system. NHSN is a secure, internet-based surveillance system that integrates patient and healthcare personnel

safety surveillance systems data and is managed by the Division of Healthcare Quality Promotion (DHQP) at the Centers for Disease Control and Prevention (CDC). In July 2008, Hospital Infection Preventionists in Oklahoma began collecting and reporting data for events related to central line associated bloodstream infections (CLABSI) and ventilator associated pneumonias (VAP). Adult patients in an intensive care unit (ICU), who were on a ventilator or who had at least one central line inserted who subsequently developed an infection meeting the strict case definition criteria defined by CDC are reported to NHSN. The data is from 2009 and 2010.

3. Hospital Compare. The Hospital

Compare website is maintained by the Centers for Medicare & Medicaid Services (CMS) and the Hospital Quality Alliance (HQA). The nation's hospitals are working together to create and publicly report hospital quality information as related to care. This information measures how well hospitals care for their patients and whether the care was paid for by Medicare, Medicaid, or a private health insurance plan.


Services Offered Licensure Hospitals in Oklahoma are required by state statute to be licensed except those hospitals operated by the federal government, state mental hospitals, and community-based structured crisis centers. Licensing Authority - The Medical Facilities Service, within Protective Health Services of the OSDH, is charged with the responsibility of assessing compliance with statute and administrative rule for hospital licensure.

Rules – Chapter 667 Hospital Standards, Title 310, of the Oklahoma Administrative Code (OAC) outlines construction standards and rules for operation in order for an entity to be licensed as a hospital in Oklahoma. Fees – The licensure fee is set by statute and is based on the total number of beds licensed by the facility multiplied by ten dollars. Renewals – A license is valid for one year, therefore, a facility must apply annually for renewal.

Facility Descriptions

Hospital – Any institution, place, building or agency, public or private, whether organized for profit or not, devoted primarily to the maintenance and operation of facilities for the diagnosis, treatment or care of patients admitted for overnight stay or longer in order to obtain medical care, surgical care, obstetrical care, or nursing care for illness, disease, injury, infirmity, or deformity [{63 O.S. § 1-701}]. In addition, Oklahoma Statutes provide that the term “hospital” includes general medical surgical hospitals, specialized hospitals, critical access and emergency hospitals, as well as birthing centers.

General Medical Surgical Hospital – A hospital maintained for the purpose of providing medical and surgical care in a broad category of illness and injury. Specialized Hospital – A hospital maintained for the purpose of providing care in a certain category, or categories, of illness and injury. The OSDH currently recognizes psychiatric, rehabilitation, and abortion facilities as specialized hospitals. Critical Access Hospital – A hospital that the OSDH determines to be a necessary provider of healthcare services to residents of a rural community.

Oklahoma Hospital Annual Report 2011

Emergency Hospital – A hospital that provides emergency treatment and stabilization services on a 24-hour basis and has the ability to admit and treat patients for a short period of time. Birthing Center – Any hospital, place, or institution which is maintained or

established primarily for the purpose of providing the services of a certified nurse, midwife, or licensed medical doctor to assist or attend in the delivery or birth and where a woman is scheduled in advance to give birth following a normal, uncomplicated, low-risk pregnancy. Licensure of birthing centers is voluntary.

Medicare Certification OSDH contracts with the Centers for Medicare & Medicaid Services (CMS) to conduct administrative and inspection activities related to certification of hospitals for participation in the federal Medicare program. Although participation in the Medicare program is voluntary, facilities opting to apply must: 1) meet the requirements outlined in the Code of Federal Regulations (CFR); Conditions of Participation for Hospitals (42 CFR part 482), and for Critical Access Hospitals, CFR Part 485; subpart F - Conditions of

Participation for Critical Access Hospitals (CAHs); and 2) comply with the Emergency Medical Treatment and Labor Act found in the Social Security Act, Sections 1866 and 1867, and associated regulations at CFR 42 part 489.24. OSDH makes recommendations regarding Medicare certification issues; however the CMS Region VI Office in Dallas, Texas has authority to make all final certification decisions.

Accreditation Several national organizations offer programs for accrediting hospitals, or parts of a hospital’s operation, by meeting the respective organizations’ published standards. Participation in such accreditation programs is voluntary. Some private accrediting bodies have been granted “deemed status” by Federal authorities. Hospitals accredited by one or more of these accrediting bodies are “deemed” to meet the applicable

federal standards without undergoing an on-site inspection by agents of CMS. There is no similar provision in Oklahoma law to grant “deemed status” to third party accrediting organizations for the purpose of state licensure.


Survey and Investigations OSDH conducts hospital site surveys for licensure and CMS certification. Also, OSDH conducts a complaint investigation when allegations have been made that a licensed hospital is non-complaint with Chapter 667 Hospital Standards. In addition, the OSDH can investigate complaints against non-accredited hospitals regarding compliance with the

Medicare Conditions of Participation. However, investigations in accredited hospitals must be authorized by CMS. Prior authorization from CMS is also required before the OSDH can conduct an investigation of compliance with the Emergency Medical Treatment and Active Labor Act (EMTALA) requirements.

Construction Reviews Licensed hospitals wishing to alter existing buildings or build a new facility must submit design plans and related documents to the OSDH for review and approval prior to construction. A review fee, based on

the project’s estimated cost for design and construction, is assessed. Final inspection and approval of the facility must be granted by the OSDH prior to occupancy.

Hospital Classifications Oklahoma Statutes require the OSDH to “develop a classification system for all hospitals that treat emergency patients. The classification system shall identify stabilizing and definitive emergency services provided by each hospital” {63 O.S. § 1-2511}. The classification system was promulgated in rule as Subchapter 59 of Chapter 667 Hospital Standards and became effective on July 13, 2000. By May 2001, each hospital in the State that offers emergency services had received an on-site visit by OSDH representatives to verify the level of service provided in each clinical category.

The system is designed to classify the level of emergency services each hospital in Oklahoma provides in ten clinical categories. Within each category, the rules identify the practitioners, hospital personnel, equipment, and support services necessary for each level of care. It should be emphasized that the classification system is not designed to be a hospital “report card.” Rather, it is intended to help direct emergency response providers and patients to the most appropriate facility based on the type and severity of their injury or illness. The ten clinical categories and levels of service follow:


• Trauma & Emergency Operative Services: Levels I – IV

• Obstetrics/Gynecology: Levels I-IV

• Ophthalmology: Levels I-III • Neurology: Levels I-III • Psychiatry: Levels I-III • Pediatric Medicine and Trauma:

Levels I-IV • Cardiology: Levels I – III • Dental: Levels I-III • General Medicine: Levels I-IV • Stroke: Primary – Secondary

The most comprehensive services are offered by hospitals classified as in a specific clinical category. These facilities are equipped and staffed to provide definitive treatment for severe emergency conditions in the classified clinical category. The hospital emergency classification system was developed with the assistance of the Oklahoma State Trauma Advisory Council, Oklahoma Emergency Response Systems Development Advisory Council, and numerous industry and professional associations.

Emergency Stroke Classification In an effort to facilitate proper treatment of strokes, Governor Brad Henry signed the Oklahoma Administrative Code, Title 310, Chapter 667 Hospital Standards in 2009, which established classification standards for "Primary Stroke Centers" and "Secondary Stroke Facilities." These standards are intended to stratify hospitals into those hospitals willing and able to administer a federal Food and Drug Administration approved intravenous thrombolytic agent to appropriate patients within one hour of arriving at the emergency department and within three hours of the onset of ischemic stroke symptoms. A Primary Stroke Center shall provide emergency medical services with an organized emergency department. A physician shall be on call and immediately available to respond to the emergency department, and nursing staff with special capability in emergent stroke

care shall be on site twenty-four hours a day. A Secondary Stroke Facility shall provide services with at least a licensed independent practitioner, registered nurse, li-censed practical nurse, or inter-mediate or paramedic level emergency medical technician on site twenty-four hours a day. However are not able or choose not to provide the therapeutic intervention for strokes are classified as a Secondary Stroke Facility. Complete hospital standards of the rules can be found in OAC 310:667-59-20.1

1

http://www.ok.gov/health2/documents/MFS%20OAC310-667_hospitaleff.07.12.pdf

http://www.ok.gov/health2/documents/MFS%20OAC310-667_hospitaleff.07.12.pdf�

http://www.ok.gov/health2/documents/MFS%20OAC310-667_hospitaleff.07.12.pdf�


Statistics at a Glance Fiscal Year 2010

152 Licensed Hospitals currently in operation: 97 General Medical Surgical Hospitals 36 Critical Access Hospitals 11 Specialized Hospitals, Psychiatric 5 Specialized Hospitals, Rehabilitation 3 Specialized Hospitals, Abortion Facility 64 Medicare Certification Surveys performed: 10 Re-certification Surveys 1 Follow-up Surveys 34 Complaint Investigations 2 Validation Survey 0 Initial Surveys 12 Life Safety 14 Licensure Surveys performed: 12 Re-licensure Surveys 0 Follow-up Surveys 2 Complaint Investigations 3 Initial Surveys

$164,635.00 Fees collected

(Note: The total dollar amount of fee collections shown above includes the fees for the Ambulatory Surgical Centers, Birthing Centers, and Workplace Drug and Alcohol Testing Facilities program areas.)


Hospital Advisory Council The Hospital Advisory Council is authorized by Oklahoma Statute (63 O.S., Section 1-707) to serve as an advisory body to the Board of Health, Commissioner and Department. The Advisory Council is composed of nine members appointed by the Commissioner with the advice and consent of the Board of Health for a three-year term. The membership consists of: two members that are hospital administrators of licensed hospitals; two members that are licensed physicians or practitioners who have current privileges to provide services in hospitals; two members that are hospital employees; and three members that are citizens representing the public who: are not hospital employees, do not hold hospital staff appointments, and are not members of hospital governing boards. The Council must meet at least quarterly, and may hold such special meetings as necessary. 2011 Advisory Board Members: Gary W. Mitchell, D.Ph. FACHE, Chair Gloria Caldwell Starla Givens, R.N. Ken Rose, Ed. D. Betty Selby Dale Harris Dale Bratzler, D.O. 2 Vacancy

The Advisory Council has the duty and authority to: (1) review and approve in its advisory capacity rules and standards for hospital licensure; (2) evaluate, review and make recommendations regarding Depart-ment licensure activities, provided, however, the Advisory Council shall not make recommendations regard-ing scope of practice for any healthcare providers or practitioners regulated pursuant to Title 59 of the Oklahoma Statues, and (3) recom-mend and approve quality indicators and data submission requirements for hospitals. The indicators and data include: Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators available as part of the standard inpatient discharge data set, and for acute care intensive care patients ventilator associated pneumonia and device–related bloodstream infections, and the indicators and data to be used by the Department to monitor com-pliance with licensure requirements. The Council has recommended the Department designate the National Healthcare Safety Network, which is maintained by the Centers for Disease Control and Prevention, as the data collection and analysis tool licensed hospitals shall use for public reporting purposes.


Patient Safety Indicators The Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators are measures used to screen for adverse events that patients experience as a result of exposure to the healthcare system; these events are likely amenable to prevention by changes at the system or provider level. The Patient Safety Indicators (PSIs) are used with the hospital inpatient discharge data, which is uploaded to the Oklahoma State Department of Health annually. The PSIs are a set of measures that can be used with hospital inpatient discharge administrative data to provide perspective on patient safety. This data is taken from the medical record billing ICD-9 codes. These are referred to as complications or adverse events. PSIs are reported at the Provider Level Indicators. Provider Level Indicators provide a measure of the potentially preventable complications for patients who received their initial care and the complication of care within the same hospitalization. Detailed information on the methods of identifying, selecting and evaluating these quality indicators can be found at the AHRQ Quality Indicator website at http://www.qualityindicators.ahrq.gov. Comparative reporting of hospital performance data is encouraged by the Agency for Healthcare Research and Quality (AHRQ). AHRQ considers comparative reporting an important strategy to advance the quality improvement agenda in healthcare. Public reporting has been supportive evidence that

comparative performance data by hospitals is a key element that promotes enhanced patient care. AHRQ works closely with the Hospital Quality Alliance (HQA), the Ambulatory Care Quality Alliance (AQA), the National Quality Forum (NQF) and others. The combined effort in comparative reporting AHRQ Quality Indicators and recommendations are submitted to the National Quality Forum endorsement process. Based on an extensive analysis of each indicator by these partners, NQF has determined the appropriateness of each indicator for comparative reporting. For the purpose of this report only the indicators classified as Tier 1 will be reported. Tier 1 has the strongest evidence base, with established evidence in several or most evidentiary areas and no substantial evidence suggesting that the indicator may not be useful for comparative reporting. Additional data from Tier 1 B will also be reported as these events are serious reportable events but may not be as useful for hospital comparison.2

2 AHRQ Quality Indications, Guidance on Using the AHRQ QI for Hospital-Level Comparative Reporting, June 2009.

http://www.qualityindicators.ahrq.gov/�

http://www.qualityindicators.ahrq.gov/�


Limitations Due to limitations related to the use of administrative data, many important concerns and potentially confounding factors cannot currently be monitored. The PSIs mainly focus on surgical indicators rather than medical or psychiatric conditions because medical complications are often difficult to distinguish from co-morbidities that are present on admission. However, the careful use of administrative data holds promise

for screening to target further data collection analysis. In small hospitals, the mathematical formula may be difficult to compute due to sample size or the number of patients (denominator) who have had the procedures. Therefore charts in this report are noted to reflect when the denominator for the specific indicator is less than ideal, because the true population at risk could not be identified from the discharge data.

Data Tables The tables are reflected by hospital groups which are defined by type: Critical Access Hospitals, General Medical Surgical Non-accredited Hospitals, General Medical Surgical Accredited Hospitals and Rehabilitation Hospitals. Some hospitals may not be represented since the data is representative of 2008 and 2009; hospital ownership may have changed or a hospital may have closed since the data was collected. Also name change may have occurred. The data represented on the charts are the number of patients affected for an event per 1000 patient discharges or with PSI # 18 through 19, it is per 1000 live births. The number is represented in red if the rate is above the state rate. If the number is represented in black it is a favorable representation. The ultimate goal is to have zero events for each of the Patient Safety

Indicators. It is also important to note that if a hospital does not have incidents of the event or licensure status has changed during the year or the patient population is less than 10 for an event, then a not applicable (NA) is listed on the chart to ensure patient confidentiality.


Definition of Terms

Critical Access Hospital (CAH) A licensed hospital is determined by the Oklahoma State Department of Health to be a necessary provider of healthcare services to residents of a rural community. The CAH shall be

the sole provider of hospital services in the community and is to allow the provision of primary hospital care in a rural community that is unable to support a general medical surgical hospital.

Medical Surgical Hospital Accreditation A licensed hospital that has voluntarily applied for and has been accredited by a national accreditation program meeting the requirements

and approval by Centers of Medicare and Medicaid Services in accordance with CFR 488.5 or CFR 488.6.

Medical Surgical Hospital Non-accreditated Is a licensed hospital which has not applied for or been accredited by a national accreditation program.

Rehabilitation Hospital Is a licensed hospital designed to serve either single- or multiple-disability categories of illness including but not limited to: cerebrovascular, head trauma, spinal cord injury, amputees, complicated fractures, arthritis, neurological

degeneration, genetic abnormalities, and cardiac rehabilitation. In general, rehabilitation hospitals and units shall have larger space requirements than general medical surgical hospitals, have longer lengths of stay, and have less institutional and more residential environments.


AHRQ Tier 1 Patient Safety Indicators (PSI) in this tier has the strongest evidence base. The National Quality Forum has endorsed these indicators. The following PSIs are included in Tier 1:

• PSI #4 Death among Surgical Inpatients with Treatable Serious Complications

• PSI #6 Iatrogenic Pneumothorax • PSI #11 Postoperative Respiratory Failure • PSI #12 Postoperative Deep Vein Thrombosis (DVT) or Pulmonary

Embolism (PE) • PSI #14 Postoperative Wound Dehiscence • PSI #15 Accidental Puncture or Laceration • PSI #18 OB Trauma-Vaginal Delivery with Instrument-assisted Delivery • PSI #19 OB Trauma-Vaginal Delivery without Instrument-assisted Delivery


PSI 4 Death among Surgical Inpatients with Treatable Serious Complications Description: Rate of in-hospital death per 1000 surgical discharges, defined by specific Diagnosis Related Group(DRG) codes and an ICD-9-CM code of major operating room procedure in any procedure field, age 18 years and older and with a principal procedure within 2 days of admission OR admission type of elective and with an ICD-9-CM code of potential complications of care (e.g., pneumonia, DVT/PE, sepsis, shock/cardiac arrest, or GI hemorrhage/acute ulcer) in any secondary diagnosis field. HealthGrades translated as ability to diagnose and treat in time.3

Non-accredited Medical Surgical Hospitals

Hospitals 2008 2009

State Rate 132.17 115.65 Bailey Medical Center 0.00 0.00 Grady Memorial Hospital 83.72 0.00 McBride Clinic Orthopedic Hospital, LLC 0.00 21.54 Oklahoma Surgical Hospital 0.00 21.64 Solara Hospital Shawnee 281.20 260.08 Solora Hospital Muskogee 573.94 471.65 Tahlequah City Hospital 0.00 69.22

**Data in red are above state rate

3 Health Grades Guiding America to Better Healthcare. Copyrighted 2009 Health Grades. Inc.


Accredited Medical Surgical Hospitals

Hospitals 2008 2009 State Rate 132.17 115.65

Claremore Regional Hospital NA 0.00 Comanche County Memorial Hospital 101.00 302.75 Community Hospital 0.00 0.00 Cushing Regional Hospital NA 122.07 Deaconess Hospital 154.65 189.32 Duncan Regional Hospital, Inc. 53.19 88.74 Great Plains Regional Medical Center NA 229.17 Hillcrest Hospital South 97.08 NA Hillcrest Medical Center 167.93 182.67 Integris Baptist Medical Center, Inc. 172.94 115.23 Integris Bass Baptist Health Center 171.75 0.00 Integris Canadian Valley Regional NA 191.63 Integris Grove General Hospital 0.00 322.59 Integris Southwest Medical Center of OK 198.88 107.65 Jackson County Memorial Hospital 98.34 104.12 Jane Phillips Medical Center 167.02 NA Kindred Hospital - Oklahoma City 178.19 NA McAlester Regional Health Center 86.80 63.04 Mercy Health Center, Inc. 39.77 0.00 Mercy Memorial Health Center Inc. 239.25 42.73 Midwest Regional Medical Center 39.34 71.98 Muskogee Community Hospital NA 0.00 Muskogee Regional Medical Center 78.28 0.00 Norman Regional Hospital 104.63 76.02 Norman Specialty Hospital NA 0.00 Northwest Surgical Hospital NA 0.00 Oklahoma Center for Ortho & Multi Speciality NA 0.00 Oklahoma Heart Hospital 123.43 145.01 Oklahoma Spine Hospital, L.L.C. 0.00 0.00 OU Medical Center 149.70 92.89 OU Medical Center Edmond 101.37 44.56 Saint Francis Hospital, Inc. 175.85 245.18 Saint Francis Hospital South, Inc. NA 0.00 SouthCrest Hospital NA 40.61 Southwestern Medical Center 0.00 86.35



Southwestern Regional Medical Center 205.12 146.02 St. Anthony Hospital 181.85 73.85 St. Anthony Hospital Bone and Joint 0.00 NA St. John Medical Center, Inc. 170.98 115.23 St. Mary's Regional Medical Center NA 0.00 Stillwater Medical Center 147.20 0.00 Tulsa Spine Hospital NA 0.00 Unity Health Center 93.13 181.51 Valley View Regional Hospital 73.37 127.02 Woodward Regional Hospital 288.16 0.00



PSI 6 Iatrogenic Pneumothorax Description: Rate of discharges with an ICD-9-CM code of iatrogenic pneumothorax in any secondary diagnosis field (not present on admission) among surgical and medical discharges, defined by specific DRG codes, age 18 years and older. An adverse condition caused by treatment by any health professional where a leak in the lung causes air to accumulate in the space around the lung (pleural cavity). This prevents the lung from expanding fully and hence a partial lung collapse occurs. For example, a doctor may accidentally puncture the lung during a surgical operation. This indicator is intended to flag cases of pneumothorax caused by medical care. Iatrogenic pneumothorax excludes all trauma patients because these patients may be more susceptible to non-preventable iatrogenic pneumothorax or may be miscoded for traumatic pneumothorax.

Critical Access Hospitals


Arbuckle Memorial Hospital 0.00 0.00 Atoka Memorial Hospital 0.00 0.00 Beaver County Memorial Hospital 0.00 0.00 Carnegie Tri-County Municipal Hospital 0.00 0.00 Cimarron Memorial Hospital & Nursing Home 0.00 0.00 Cleveland Area Hospital 0.00 0.00 Cordell Memorial Hospital 0.00 0.00 Creek Nation Community Hospital NA 0.00 Drumright Regional Hospital 0.00 0.00 Fairfax Memorial Hospital Inc. 0.00 0.00 Fairview Hospital 0.00 0.00 Harper County Community Hospital 0.00 0.00 Haskell County Hospital 0.00 0.00 Healdton Municipal Hospital 0.00 0.00 Holdenville General Hospital 0.00 0.00 Integris Marshall Memorial Hospital 0.00 0.00 Jane Phillips Nowata Health Center 0.00 0.00 Jefferson County Hospital 0.00 0.00 Johnston Memorial Hospital 0.00 0.00 Kingfisher Regional Hospital 0.00 0.00 Logan Medical Center 0.00 2.71 Mangum City Hospital 0.00 NA Mary Hurley Hospital 0.00 0.00



Mercy Health Love County 0.00 0.00 Okeene Municipal Hospital 0.00 0.00 Pawhuska Hospital, Inc. 0.00 NA Physicians Hospital of Anadarko 0.00 0.00 Prague Municipal Hospital 0.00 0.00 Roger Mills Memorial Hospital 0.00 0.00 Seiling Municipal Hospital 0.00 0.00 St. John Sapulpa (AKA Bartlett) 0.00 0.00 Stroud Regional Medical Center 0.00 0.00 Watonga Municipal Hospital 0.00 0.00 Weatherford Regional Hospital 0.00 0.00 **Data in red are above state rate



Bailey Medical Center 0.00 1.91 Bristow Medical Center 0.00 0.00 Choctaw Memorial Hospital 0.00 0.00 Community Hospital Lakeview 0.00 NA Continuous Care Center of Tulsa 0.00 0.00 Craig General Hospital 0.00 0.00 Eastern Oklahoma Medical Center Inc. 0.00 1.39 Elkview General Hospital 4.18 0.00 Foundation Bariatric Hospital of OK, LLC 0.00 0.00 Grady Memorial Hospital 0.80 1.22 Harmon Memorial Hospital 0.00 0.00 Henryetta Medical Center 0.00 0.00 Latimer County General Hospital 0.00 0.00 Lindsay Municipal Hospital 0.00 0.00 McBride Clinic Orthopedic Hospital, LLC 0.00 0.00 McCurtain Memorial Hospital 0.00 0.00 Memorial Hospital & Physician Group 0.00 0.00 Memorial Hospital of Stilwell 0.00 1.67 Memorial Hospital of Texas County 4.13 0.00



Newman Memorial Hospital 2.62 0.00 Oklahoma Surgical Hospital 0.00 0.00 Okmulgee Memorial Hospital 1.34 2.12 Orthopedic Hospital 0.00 0.00 Park View Hospital 0.00 0.00 Pauls Valley General Hospital 0.00 0.00 Perry Memorial Hospital 0.00 0.00 Purcell Municipal Hospital 0.00 0.00 Pushmataha Hospital 0.00 0.00 Sayre Memorial Hospital 0.00 0.00 Sequoyah Memorial Hospital 0.00 0.00 Share Memorial Hospital 0.00 0.00 Solara Hospital Shawnee 0.00 0.00 Solora Hospital Muskogee 0.00 0.00 St John Owasso 0.00 0.00 Tahlequah City Hospital 0.46 0.00 Wagoner Community Hospital 0.00 0.00 **Data in red are above state rate




Bone and Joint Hospital 0.00 NA Claremore Regional Hospital 1.11 0.00 Comanche County Memorial Hospital 0.90 0.00 Community Hospital 1.29 1.95 Cushing Regional Hospital 0.00 0.00 Deaconess Hospital 1.68 1.81 Duncan Regional Hospital, Inc. 0.85 0.00 Edmond Medical Center 1.67 1.80 Edmond Specialty Hospital 0.00 NA Great Plains Regional Medical Center 0.80 0.00 Hillcrest Medical Center 0.43 0.00 Integris Baptist Medical Center, Inc. 0.89 0.91 Integris Baptist Regional Health Center 0.55 NA Integris Bass Baptist Health Center 0.00 0.00 Integris Bass Pavilion 4.25 0.00 Integris Blackwell Regional Hospital 0.00 0.00 Integris Canadian Valley Regional Hospital 1.77 0.00 Integris Clinton Regional Hospital 2.65 0.00 Integris Grove General Hospital 0.00 2.42 Integris Mayes County Medical Center 0.00 2.77 Integris Seminole Medical Center 0.00 0.00 Integris Southwest Medical Center of OK 0.93 1.13 Jackson County Memorial Hospital 1.55 1.51 Jane Phillips Medical Center 0.69 1.79 Kindred Hospital - Oklahoma City 1.79 NA Lakeside Women's Hospital 0.00 0.00 McAlester Regional Health Center 0.91 0.51 Medical Center of Southeastern Oklahoma 0.49 0.00 Mercy Health Center, Inc. 0.96 0.19 Mercy Memorial Health Center Inc. 2.95 1.41 Midwest Regional Medical Center 0.34 0.63 Muskogee Regional Medical Center 1.28 0.00



Norman Regional Hospital 0.79 1.19 Norman Specialty Hospital 0.00 0.00 Northwest Surgical Hospital 0.00 0.00 Oklahoma Center for Orthopedic & Multi Specialty Surgery 0.00 0.00 Oklahoma Heart Hospital 3.12 2.85 Oklahoma Spine Hospital, L.L.C. 0.00 0.00 OSU Medical Center 2.51 3.62 OU Medical Center 1.32 4.76 Ponca City Medical Center 0.00 0.81 Saint Francis Hospital South 1.56 0.00 Saint Francis Hospital, Inc. 1.24 1.35 Select Specialty Hospital, Tulsa 0.00 0.00 Select Specialty Hospital-Oklahoma City 0.00 1.58 SouthCrest Hospital 0.44 0.63 Southwestern Medical Center 0.00 0.70 Southwestern Regional Medical Center 0.00 3.37 Specialty Hospital of Midwest City 0.00 9.19 St. Anthony Hospital 0.45 0.72 St. John Medical Center, Inc. 2.21 2.89 St. Mary's Regional Medical Center 2.64 0.70 Stillwater Medical Center 0.00 2.76 Surgical Hospital of Oklahoma 0.00 0.00 Unity Health Center 0.80 0.00 Valley View Regional Hospital 1.14 0.52 Woodward Regional Hospital 0.94 4.01 **Data in red are above state rate

Rehabilitation Hospitals


George Nigh Rehabilitation Institute 0.00 0.00 J. D. McCarty Center for Children with Developmental Disabilities 0.00 0.00 Lane Frost Health and Rehabilitation Center 0.00 0.00 Valir Rehabilitation Hospital of OKC, LLC 0.00 2.89 **Data in red are above stat


PSI 11 Postoperative Respiratory Failure Description: Rate of discharges with an ICD-9-CM code of acute respiratory failure in any secondary diagnosis field (not present on admission) or an ICD-9-CM code for re-intubation procedure in any procedure field that is zero, one or two or more days after the major operating room procedure (depending on the code) among elective surgical discharges, defined by specific DRG codes and an ICD-9-CM code of major operating room procedure in any procedure field, age 18 and older. The goal is to avoid respiratory failure following a surgery procedure.


Hospital 2008 2009 State Rate 13.17 19.42

Drumright Regional Hospital 0.00 0.00 Haskell County Hospital 0.00 0.00 Kingfisher Regional Hospital NA 0.00 St. John Sapulpa (AKA Bartlett) 0.00 0.00 Stroud Regional Medical Center 0.00 NA Weatherford Regional Hospital NA 0.00 **Data in red are above state rate


Hospital 2008 2009

State Rate 13.17 19.42 Bailey Medical Center 11.32 13.36 Choctaw Memorial Hospital NA 0.00 Claremore Regional Hospital NA 0.00 Craig General Hospital NA 0.00 Eastern Oklahoma Medical Center Inc. 13.70 49.33 Elkview General Hospital 0.00 0.00 Foundation Bariatric Hospital of OK, LLC 0.00 12.59 Grady Memorial Hospital 8.79 7.52 Henryetta Medical Center 0.00 0.00 Lindsay Municipal Hospital 0.00 0.00 McBride Clinic Orthopedic Hospital, LLC 0.00 0.00 McCurtain Memorial Hospital 0.00 0.00 Memorial Hospital of Stilwell 0.00 0.00



Memorial Hospital of Texas County 31.15 0.00 Newman Memorial Hospital 0.00 0.00 Oklahoma Surgical Hospital 0.41 1.43 Okmulgee Memorial Hospital 0.00 NA Orthopedic Hospital 0.00 13.59 Pauls Valley General Hospital 0.00 64.59 Purcell Municipal Hospital 0.00 0.00 Solara Hospital Shawnee 15.62 17.37 Solara Hospital Muskogee NA 68.10 St John Owasso 0.00 0.00 Tahlequah City Hospital 7.81 18.18 Wagoner Community Hospital 0.00 0.00




Bone and Joint Hospital 1.03 NA Comanche County Memorial Hospital 15.85 35.75 Community Hospital 11.67 12.95 Cushing Regional Hospital 25.57 20.14 Deaconess Hospital 24.26 20.33 Duncan Regional Hospital, Inc. 17.82 14.87 Edmond Medical Center 27.95 21.58 Great Plains Regional Medical Center 15.81 29.25 Hillcrest Medical Center 20.62 30.12 Integris Baptist Medical Center, Inc. 23.71 30.52 Integris Bass Baptist Health Center 23.05 18.15 Integris Blackwell Regional Hospital 0.00 15.16 Integris Canadian Valley Regional Hospital 13.59 22.91



Integris Clinton Regional Hospital 0.00 137.01 Integris Grove General Hospital 16.39 7.34 Integris Mayes County Medical Center 0.00 0.00 Integris Seminole Medical Center 0.00 0.00 Integris Southwest Medical Center of OK 32.47 41.41 Jackson County Memorial Hospital 20.10 23.25 Jane Phillips Medical Center 9.17 7.34 Kindred Hospital - Oklahoma City 27.36 NA Lakeside Women's Hospital 0.00 0.00 McAlester Regional Health Center 15.19 23.65 Mercy Health Center, Inc. 17.88 17.61 Mercy Memorial Health Center Inc. 9.79 34.68 Midwest Regional Medical Center 5.96 8.94 Muskogee Community Hospital NA 4.15 Muskogee Regional Medical Center 17.81 24.67 Norman Regional Hospital 16.19 15.86 Norman Specialty Hospital 0.00 7.43 Northwest Surgical Hospital 0.00 0.00 Oklahoma Center for Orthopedic & Multi Specialty Surgery 0.00 0.00 Oklahoma Heart Hospital 10.42 6.34 Oklahoma Spine Hospital, L.L.C. 0.00 0.00 OU Medical Center 20.54 35.92 Saint Francis Hospital at Broken Arrow 10.06 25.59 Saint Francis Hospital, Inc. 10.12 20.38 Select Specialty Hospital, Tulsa 38.90 0.00 Select Specialty Hospital-Oklahoma City 27.57 0.00 SouthCrest Hospital 13.58 37.23 Southwestern Medical Center 5.46 23.07 Southwestern Regional Medical Center 36.44 28.37 Specialty Hospital of Midwest City NA 0 St. Anthony Hospital 9.99 14.99



St. John Medical Center, Inc. 9.69 15.97 Stillwater Medical Center 15.67 33.62 Surgical Hospital of Oklahoma, L.L.C. 0.00 0.00 Tulsa Spine Hospital NA 1.27 Unity Health Center 4.81 30.23 Valley View Regional Hospital 20.69 24.98 Woodward Regional Hospital 26.82 15.51



PSI 12 Postoperative Pulmonary Embolism or Deep Vein Thrombosis Description: Rate of discharges with an ICD-9-CM code of deep vein thrombosis or pulmonary embolism in any secondary diagnosis field (not present on admission) among surgical discharges, defined by specific DRG codes and an ICD-9-CM code of major operating room procedure in any procedure field, age 18 and older. Deep vein thrombosis is a blood clot in a deep vein. The blood clot commonly occurs in the deeper veins in the thigh or calf, but may occur in the deep veins of the arms. A blood clot is also called a thrombus. The condition can be very painful and can lead to serious complications. Pulmonary embolism is a blocked lung blood vessel, often from a blood clot. This indicator is intended to capture cases of postoperative venous thromboses and embolism – specifically, pulmonary embolism and deep venous thrombosis. It further excludes patients who have principal diagnosis of deep vein thrombosis, as these patients are likely to have a pulmonary embolism/deep vein thrombosis present on admission.



Drumright Regional Hospital 12.10 0.00 Haskell County Hospital 0.00 0.00 Kingfisher Regional Hospital 0.00 0.00 Logan Medical Center 22.81 0.00 Okeene Municipal Hospital 0.00 0.00 Physicians Hospital of Anadarko 0.00 166.23 St. John Sapulpa (AKA Bartlett) 0.00 0.00 Stroud Regional Medical Center 0.00 0.00 Weatherford Regional Hospital 0.00 0.00 **Data in red are above state rate

http://www.wrongdiagnosis.com/sym/blood_clot.htm�




Bailey Medical Center 3.29 10.68 Choctaw Memorial Hospital 0.00 0.00 Continuous Care Center of Tulsa 19.66 26.98 Craig General Hospital 0.00 0.00 Eastern Oklahoma Medical Center Inc. 8.22 9.89 Elkview General Hospital 11.23 0.00 Foundation Bariatric Hospital of OK, 9.86 0.00 Grady Memorial Hospital 15.49 8.44 Henryetta Medical Center 0.00 0.00 Lindsay Municipal Hospital 13.62 0.00 McBride Clinic Orthopedic Hospital, LLC 4.41 12.52 McCurtain Memorial Hospital 17.25 32.87 Memorial Hospital and Physician Group NA 0.00 Memorial Hospital of Stilwell 16.87 10.28 Memorial Hospital of Texas County 9.90 0.00 Newman Memorial Hospital 0.00 0.00 Oklahoma Surgical Hospital 2.68 2.10 Okmulgee Memorial Hospital 11.94 0.00 Orthopedic Hospital 0.00 0.00 Park View Hospital 15.83 45.14 Pauls Valley General Hospital 0.00 18.50 Purcell Municipal Hospital 0.00 0.00 Pushmataha Hospital 0.00 0.00 Sayre Memorial Hospital 0.00 0.00 Sequoyah Memorial Hospital NA 0.00 Solara Hospital Shawnee 40.26 15.22 Solora Hospital Muskogee 23.72 17.65 St John Owasso 0.00 13.44



Tahlequah City Hospital 10.84 8.12 Wagoner Community Hospital 0.00 0.00 **Data in red are above state rate



Bone and Joint Hospital 5.45 NA Claremore Regional Hospital 0.00 10.72 Comanche County Memorial Hospital 5.88 6.67 Community Hospital 1.89 5.7 Cushing Regional Hospital 13.95 7.62 Deaconess Hospital 4.51 6.91 Duncan Regional Hospital, Inc. 5.24 3.86 Edmond Medical Center 17.89 8.45 Edmond Specialty Hospital 156.37 NA Great Plains Regional Medical Center 2.77 0.00 Hillcrest Medical Center 8.23 7.48 Integris Baptist Medical Center, Inc. 12.82 8.59 Integris Baptist Regional Health Center 6.57 9.52 Integris Bass Baptist Health Center 7.31 6.68 Integris Bass Pavilion 62.59 40.87 Integris Blackwell Regional Hospital 0.00 0.00 Integris Canadian Valley Regional Hospital 5.91 2.37 Integris Clinton Regional Hospital 0.00 0.00 Integris Grove General Hospital 10.57 7.34 Integris Mayes County Medical Center 0.00 13.25 Integris Seminole Medical Center 16.24 0.00



Integris Southwest Medical Center of OK 10.60 6.36 Jackson County Memorial Hospital 5.54 4.60 Jane Phillips Medical Center 1.94 2.81 Kindred Hospital - Oklahoma City 39.21 NA Lakeside Women's Hospital 0.00 0.00 McAlester Regional Health Center 6.36 2.97 Medical Center of Southeastern Oklahoma 2.80 1.44 Mercy Health Center, Inc. 14.85 9.33 Mercy Memorial Health Center Inc. 9.69 8.24 Midwest Regional Medical Center 6.12 6.24 Muskogee Community Hospital NA 3.43 Muskogee Regional Medical Center 16.67 9.85 Norman Regional Hospital 6.14 8.02 Norman Specialty Hospital 116.94 33.33 Northwest Surgical Hospital 4.70 11.08 Oklahoma Center for Orthopedic & Multi Specialty Surgery 0.00 0.00 Oklahoma Heart Hospital 5.06 5.72 Oklahoma Spine Hospital, L.L.C. 0.69 2.07 OSU Medical Center 13.50 9.11 OU Medical Center 28.52 28.03 Ponca City Medical Center 2.87 6.80 Saint Francis Hospital South 6.95 10.09 Saint Francis Hospital, Inc. 10.81 9.86 Select Specialty Hospital, Tulsa 52.63 16.72 Select Specialty Hospital-Oklahoma City 24.62 10.55



SouthCrest Hospital 12.95 5.97 Southwestern Medical Center 13.06 9.85 Southwestern Regional Medical Center 14.90 29.18 Specialty Hospital of Midwest City 0.00 0.00 St. Anthony Hospital 6.86 9.80 St. John Medical Center, Inc. 12.39 10.24 St. Mary's Regional Medical Center NA 5.99 Stillwater Medical Center 4.50 7.76 Surgical Hospital of Oklahoma 2.92 0.00 Tulsa Spine Hospital NA 0.93 Unity Health Center 6.32 2.25 Valley View Regional Hospital 6.18 3.12 Woodward Regional Hospital 7.72 4.43 **Data in red are above state rate


PSI 14 Postoperative Wound Dehiscence Description: Rate of discharges with an ICD-9-CM code of reclosure of postoperative disruption of abdominal wall in any procedure field among abdominopelvic surgical discharges, defined by specific ICD-9-CM codes, age 18 and older. Wound dehiscence is the parting of the layers of a surgical wound. This indicator is intended to flag cases of wound dehiscence in patients who have undergone abdominal and pelvic surgery.



Drumright Regional Hospital 0.00 0.00 Haskell County Hospital NA 0.00 Kingfisher Regional Hospital NA 0.00 Logan Medical Center 0.00 0.00 Okeene Municipal Hospital 0.00 0.00 St. John Sapulpa NA 0.00 Stroud Regional Medical Center NA 0.00



Bailey Medical Center 0.00 0.00 Choctaw Memorial Hospital 0.00 0.00 Craig General Hospital NA 0.00 Eastern Oklahoma Medical Center Inc. 0.00 20.05 Elkview General Hospital 0.00 0.00 Foundation Bariatric Hospital of OK, LLC 0.00 0.00 Grady Memorial Hospital 0.00 0.00 Lindsay Municipal Hospital 0.00 89.11 McCurtain Memorial Hospital 0.00 0.00 Memorial Hospital of Stilwell 0.00 0.00 Memorial Hospital of Texas County 0.00 0.00 Newman Memorial Hospital 0.00 0.00 Oklahoma Surgical Hospital 0.00 0.00 Okmulgee Memorial Hospital 0.00 0.00 Park View Hospital 0.00 0.00



Pauls Valley General Hospital 0.00 0.00 Pushmataha Hospital 0.00 0.00 St John Owasso 0.00 0.00 Tahlequah City Hospital 0.00 0.00




Bone and Joint Hospital 0.00 NA Claremore Regional Hospital 0.00 0.00 Comanche County Memorial Hospital 2.70 0.00 Community Hospital NA 0.00 Cushing Regional Hospital 0.00 0.00 Deaconess Hospital 0.00 2.25 Duncan Regional Hospital, Inc. 0.00 0.00 Edmond Medical Center 7.35 0.00 Great Plains Regional Medical Center 11.08 0.00 Hillcrest Medical Center 0.00 1.69 Integris Baptist Medical Center, Inc. 1.37 2.33 Integris Baptist Regional Health Center 0.00 0.00 Integris Bass Baptist Health Center 0.00 5.74 Integris Blackwell Regional Hospital 0.00 0.00 Integris Canadian Valley Regional Hospital 6.59 0.00 Integris Clinton Regional Hospital 0.00 0.00 Integris Grove General Hospital 11.52 8.93 Integris Mayes County Medical Center 55.85 0.00 Integris Seminole Medical Center 35.32 0.00 Integris Southwest Medical Center of OK 1.70 1.86 Jackson County Memorial Hospital 0.00 0.00 Jane Phillips Medical Center 2.57 3.70 Lakeside Women's Hospital 0.00 0.00 McAlester Regional Health Center 13.05 11.34 Medical Center of Southeastern Oklahoma 9.28 0.00 Mercy Health Center, Inc. 4.87 3.59 Mercy Memorial Health Center Inc. 0.00 0.00



Midwest Regional Medical Center 4.07 0.00 Muskogee Community Hospital NA 0.00 Muskogee Regional Medical Center 0.00 3.91 Norman Regional Hospital 1.26 0.00 Northwest Surgical Hospital 0.00 0.00 Oklahoma Center for Orthopedic & Multi Specialty Surgery 0.00 0.00 Oklahoma Heart Hospital 0.00 0.00 OSU Medical Center 6.88 3.56 OU Medical Center 2.14 0.00 Ponca City Medical Center 5.98 0.00 Saint Francis Hospital South 11.22 0.00 Saint Francis Hospital, Inc. 1.65 0.55 SouthCrest Hospital 5.35 3.25 Southwestern Medical Center 0.00 0.00 Southwestern Regional Medical Center 6.29 0.00 St. Anthony Hospital 0.00 5.85 St. John Medical Center, Inc. 3.12 2.65 St. Mary's Regional Hospital NA 4.02 Stillwater Medical Center 0.00 0.00 Surgical Hospital of Oklahoma, L.L.C. 0.00 0.00 Unity Health Center 5.67 6.61 Valley View Regional Hospital 3.21 0.00 Woodward Regional Hospital 12.70 0.00



PSI 15 Accidental Puncture or Laceration Description: Rate of discharges with an ICD-9-CM code of accidental cut, puncture, perforation or laceration during a procedure in any secondary diagnosis field (not present on admission) among surgical and medical discharges, defined by specific DRG codes, age 18 years and older. The event is an accidental cut or laceration, which occurred during a hospital stay while receiving medical care. This indicator is intended to flag cases of complications that arise due to technical difficulties in medical care – specifically, those involving an accidental puncture or laceration.



Arbuckle Memorial Hospital 0.00 0.00 Beaver County Memorial Hospital NA 0.00 Carnegie Tri-County Municipal Hospital 0.00 0.00 Cimarron Memorial Hospital & Nursing Home 0.00 0.00 Cleveland Area Hospital 0.00 0.00 Cordell Memorial Hospital 0.00 0.00 Creek National Community Hospital NA 0.00 Drumright Regional Hospital 0.00 2.52 Fairfax Memorial Hospital Inc. 0.00 0.00 Fairview Hospital 0.00 NA Harper County Community Hospital 0.00 0.00 Haskell County Hospital 0.00 0.00 Healdton Municipal Hospital 0.00 0.00 Holdenville General Hospital 0.00 0.00 Integris Marshall Memorial Hospital 0.00 0.00 Jane Phillips Nowata Health Center 0.00 0.00 Jefferson County Hospital 4.97 0.00 Johnston Memorial Hospital 0.00 0.00 Kingfisher Regional Hospital 0.00 0.00 Logan Medical Center 0.00 0.00 Mangum City Hospital 0.00 0.00 Mary Hurley Hospital 0.00 0.00



Mercy Health Love County 0.00 0.00 Okeene Municipal Hospital 0.00 0.00 Pawhuska Hospital, Inc. 0.00 0.00 Physicians Hospital of Anadarko 0.00 0.00 Prague Municipal Hospital 0.00 0.00 Quartz Mountain Medical Center NA 0.00 Roger Mills Memorial Hospital 0.00 0.00 Seiling Municipal Hospital 0.00 0.00 St. John Sapulpa (AKA Bartlett) 0.00 0.00 Stroud Regional Medical Center 0.00 6.60 Watonga Municipal Hospital 2.81 0.00 Weatherford Regional Hospital 0.00 0.00



Hospital 2008 2009

State Rate 3.14 3.66 Bailey Medical Center 6.72 5.83 Bristow Medical Center 0.00 0.00 Choctaw Memorial Hospital 0.00 0.00 Community Hospital Lakeview 0.00 NA Continuous Care Center of Tulsa 0.00 0.00 Craig General Hospital 0.00 1.55 Eastern Oklahoma Medical Center Inc. 0.00 0.00 Elkview General Hospital 3.56 0.00 EPIC Medical Center NA 0.00 Foundation Bariatric Hospital of OK, LLC 0.00 12.44 Grady Memorial Hospital 5.23 11.53 Harmon Memorial Hospital 0.00 0.00 Henryetta Medical Center 0.00 0.00 Latimer County General Hospital 0.00 0.00 Lindsay Municipal Hospital 3.06 0.00 McBride Clinic Orthopedic Hospital, LLC 0.00 0.00 McCurtain Memorial Hospital 0.83 3.28 Memorial Hospital & Physician Group 0.00 0.00



Memorial Hospital of Stillwell NA 1.85 Memorial Hospital of Texas County 1.60 0.00 Newman Memorial Hospital 4.11 0.00 Oklahoma Surgical Hospital 8.41 7.25 Okmulgee Memorial Hospital 1.04 3.05 Orthopedic Hospital 0.00 0.00 Park View Hospital 0.00 0.00 Pauls Valley General Hospital 0.90 2.15 Perry Memorial Hospital 0.00 0.00 Purcell Municipal Hospital 0.00 0.00 Pushmataha Hospital 0.00 0.00 Sayre Memorial Hospital NA 0.00 Sequoyah Memorial Hospital 0.00 5.52 Share Memorial Hospital 0.00 0.00 Solara Hospital Shawnee 4.75 8.69 Solora Hospital Muskogee 0.00 0.00 St John Owasso 1.35 1.76 Tahlequah City Hospital 2.56 5.83 Wagoner Community Hospital 0.00 0.00



Hospital 2008 2009

State Rate 3.14 3.66 Bone and Joint Hospital 2.58 NA Claremore Regional Hospital 1.21 0.63 Comanche County Memorial Hospital 3.90 6.14 Community Hospital 7.22 3.28 Cushing Regional Hospital 0.92 0.00 Deaconess Hospital 2.10 3.66 Duncan Regional Hospital, Inc. 2.31 0.00 Edmond Medical Center 7.40 8.53 Edmond Specialty Hospital 0.00 NA George Nigh Long Term Acute Care Hospital NA 0.00 Great Plains Regional Medical Center 4.42 2.76 Hillcrest Medical Center 4.58 3.25



Integris Baptist Medical Center, Inc. 2.57 2.38 Integris Baptist Regional Health Center 1.74 2.61 Integris Bass Baptist Health Center 3.94 3.78 Integris Bass Pavilion 0.00 0.00 Integris Blackwell Regional Hospital 2.35 5.73 Integris Canadian Valley Regional Hospital 3.01 0.73 Integris Clinton Regional Hospital 0.00 0.00 Integris Grove General Hospital 0.50 2.31 Integris Mayes County Medical Center 2.95 0.00 Integris Seminole Medical Center 2.20 0.00 Integris Southwest Medical Center of OK 0.90 0.73 Jackson County Memorial Hospital 0.86 1.67 Jane Phillips Medical Center 6.26 6.15 Kindred Hospital - Oklahoma City 0.00 NA Lakeside Women's Hospital 0.00 0.00 McAlester Regional Health Center 2.31 1.31 Medical Center of Southeastern Oklahoma 0.22 1.01 Mercy Health Center, Inc. 4.31 6.69 Mercy Memorial Health Center Inc. 3.68 6.48 Midwest Regional Medical Center 2.30 2.96 Muskogee Community Hospital NA 0.95 Muskogee Regional Medical Center 0.97 6.71 Norman Regional Hospital 3.06 3.83 Norman Specialty Hospital NA 0.00 Northwest Surgical Hospital NA 8.53 Oklahoma Center for Orthopedic & Multi Specialty Surgery 0.00 6.81 Oklahoma Heart Hospital 2.87 2.68 Oklahoma Spine Hospital, L.L.C. 6.10 0.00 OSU Medical Center 8.33 5.68 OU Medical Center 4.50 7.40 Ponca City Medical Center 2.85 1.84 Saint Francis Hospital South 1.69 4.65 Saint Francis Hospital, Inc. 3.96 3.18 Select Specialty Hospital, Tulsa 0.00 0.00 Select Specialty Hospital-Okla City 0.00 0.00



SouthCrest Hospital 3.51 4.43 Southwestern Medical Center 5.96 3.31 Southwestern Regional Medical Center 1.13 0.00 Specialty Hospital of Midwest City 0.00 0.00 St. Anthony Hospital 3.24 4.33 St. John Medical Center, Inc. 4.60 3.96 St. Mary's Regional Medical Center 7.52 3.04 Stillwater Medical Center 3.68 5.55 Surgical Hospital of Oklahoma, L.L.C. 6.05 8.07 Tulsa Spine Hospital NA 0.00 Unity Health Center 3.06 3.33 Valley View Regional Hospital 1.97 1.49 Woodward Regional Hospital 7.38 7.30


Rehabilitation Hospitals


Lane Frost Health and Rehabilitation Center NA 0.00 J.D. McCarty Center for Children NA 0.00 George Nigh Rehabilitation Institute 0.00 0.00 Valir Rehabilitation Hospital of OKC, LLC 0.00 8.55



PSI 18 Obstetric Trauma – Vaginal Delivery with Instrument Description: Rate of discharges with an ICD-9-CM code of 3rd and 4th degree obstetric laceration in any diagnosis field among vaginal delivery discharges, defined by DRG, with an ICD-9-CM code of instrument-assisted delivery in any procedure field. This event occurs during a vaginal delivery using an obstetric instrument and a severe laceration results, such as a tear extending into the deep transverse perineal muscles and fibers of the anal sphincter (third degree) or rectal mucosa (fourth degree). This indicator is intended to flag cases of potentially preventable trauma during vaginal delivery with instrument.


Hospital 2008 2009.00 State Rate 129.65 131.26

Kingfisher Regional Hospital NA 250.00 Weatherford Regional Hospital 264.71 241.38




Craig General Hospital 90.91 55.56 Eastern Oklahoma Medical Center Inc. 106.67 60.00 Grady Memorial Hospital 0.00 148.15 McCurtain Memorial Hospital 114.29 111.11 Memorial Hospital of Texas County 64.52 114.28 Pauls Valley General Hospital NA 333.33 St. John Owasso NA 571.43 Tahlequah City Hospital 115.38 0.00





Claremore Regional Hospital 0.00 0.00 Comanche County Memorial Hospital 58.82 173.91 Cushing Regional Hospital 74.07 58.82 Deaconess Hospital 59.32 98.36 Duncan Regional Hospital, Inc. 83.33 108.10 Great Plains Regional Medical Center 113.64 98.04 Hillcrest Medical Center 177.78 137.14 Integris Baptist Medical Center, Inc. 150.86 122.95 Integris Baptist Regional Health Center 181.82 200.00 Integris Bass Baptist Health Center 146.67 139.53 Integris Blackwell Regional Hospital 80.00 111.11 Integris Canadian Valley Regional Hospital 162.16 131.58 Integris Clinton Regional Hospital 38.46 142.86 Integris Grove General Hospital 21.74 42.55 Integris Mayes County Medical Center 0.00 111.11 Integris Southwest Medical Center of OK 57.14 69.23 Jackson County Memorial Hospital 76.92 100.00 Jane Phillips Medical Center 125.00 191.71 Lakeside Women's Hospital 157.89 98.04 McAlester Regional Health Center NA 200.00 Medical Center of Southeastern Oklahoma 33.90 46.88 Mercy Health Center, Inc. 168.83 189.87 Mercy Memorial Health Center Inc. 108.91 132.74 Midwest Regional Medical Center 156.25 52.63 Muskogee Regional Medical Center 54.05 57.14 Norman Regional Hospital 114.68 84.11 OSU Medical Center 125.00 125.00 OU Medical Center 181.82 141.73 Ponca City Medical Center 121.21 125.00 Saint Francis Hospital South 43.48 135.14 Saint Francis Hospital, Inc. 211.98 158.87 SouthCrest Hospital 153.06 235.95 Southwestern Medical Center 107.14 37.04



St. Anthony Hospital 60.81 83.33 St. John Medical Center, Inc. 198.35 217.82 St. Mary's Regional Medical Center NA 176.47 Stillwater Medical Center 155.34 132.65 Unity Health Center 223.68 148.15 Valley View Regional Hospital 118.64 117.65 Woodward Regional Hospital 100.00 NA

**Data in red are above state rat


PSI 19 Obstetric Trauma – Vaginal Delivery without Instrument Description: Rate of discharges with an ICD-9-CM code of 3rd and 4th degree obstetric trauma in any diagnosis field among vaginal delivery discharges, defined by DRG, without an ICD-9-CM code of instrument-assisted delivery in any procedure field. This event occurs during a vaginal delivery without the use of an obstetric instrument and a severe laceration results, such as a tear extending into the deep transverse perineal muscles and fibers of the anal sphincter (third degree) or rectal mucosa (fourth degree). This indicator is intended to flag cases of potentially preventable trauma during vaginal delivery without instrument.



Harper County Community Hospital 55.56 0.00 Kingfisher Regional Hospital 86.21 68.18 Memorial Hospital of Stillwell NA 111.11 Weatherford Regional Hospital 24.00 26.09




Bailey Medical Center 108.70 11.23 Craig General Hospital 0.00 0.00 Eastern Oklahoma Medical Center Inc. 19.23 14.85 Grady Memorial Hospital 11.24 23.39 McCurtain Memorial Hospital 101.35 174.7 Memorial Hospital of Stilwell 37.04 NA Memorial Hospital of Texas County 19.61 0.00 Newman Memorial Hospital 24.59 22.06 Park View Hospital 90.91 117.02 Pauls Valley General Hospital 34.48 15.87 Purcell Municipal Hospital 86.96 34.48 St John Owasso 24.39 87.21 Tahlequah City Hospital 5.00 14.02 **Data in red are above state rate




Claremore Regional Hospital 19.18 8.69 Comanche County Memorial Hospital 17.65 15.56 Cushing Regional Hospital 22.99 33.11 Deaconess Hospital 21.41 17.27 Duncan Regional Hospital, Inc. 27.86 12.65 Great Plains Regional Medical Center 40.00 13.42 Hillcrest Medical Center 21.90 18.76 Integris Baptist Medical Center, Inc. 30.52 27.37 Integris Baptist Regional Health Center 13.29 20.74 Integris Bass Baptist Health Center 33.99 39.86 Integris Blackwell Regional Hospital 20.41 57.14 Integris Canadian Valley Regional Hospital 55.77 42.39 Integris Clinton Regional Hospital 16.13 16.39 Integris Grove General Hospital 19.48 7.09 Integris Mayes County Medical Center 0.00 7.19 Integris Southwest Medical Center of OK 15.31 15.47 Jackson County Memorial Hospital 13.89 8.13 Jane Phillips Medical Center 29.06 26.1 Lakeside Women's Hospital 24.66 23.16 McAlester Regional Health Center 41.06 47.39 Medical Center of Southeastern Oklahoma 4.62 1.48 Mercy Health Center, Inc. 29.82 19.05 Mercy Memorial Health Center Inc. 17.99 26.22 Midwest Regional Medical Center 43.08 36.9 Muskogee Regional Medical Center 12.74 12.13 Norman Regional Hospital 29.77 24.47 OSU Medical Center 24.76 21.74 OU Medical Center 18.65 16.37 Ponca City Medical Center 28.67 20.55 Saint Francis Hospital South 48.33 35.09 Saint Francis Hospital, Inc. 41.53 25.89 SouthCrest Hospital 17.37 22.74 Southwestern Medical Center 25.97 17.39



St. Anthony Hospital 9.38 14.64 St. John Medical Center, Inc. 39.88 63.58 St. Mary's Regional Medical Center 30.41 22.6 Stillwater Medical Center 40.97 51.72 Unity Health Center 35.61 36.55 Valley View Regional Hospital 9.84 5.59 Woodward Regional Hospital 0.00 12.19



AHRQ Tier 1-B A subset of Tier 1, are serious reportable events that are most suitable for public accountability and root cause analysis, but for which comparisons between hospitals may not be useful. The National Quality Forum has endorsed the following PSIs which are included in Tier 1-B:

• PSI #02 Death in Low Mortality Diagnosis Related Groupings (DRGs) • PSI #08 Postoperative Hip Fracture

PSI 2 Death in Low Mortality DRGs

Description: Rate of in-hospital death among discharges with a DRG code for a low mortality DRG (defined as a mortality rate of less than 0.5%).



Arbuckle Memorial Hospital 7.79 0.00 Atoka Memorial Hospital 0.00 0.00 Carnegie Tri-County Municipal Hospital 0.00 0.00 Cimarron Memorial Hospital NA 0.00 Cordell Memorial Hospital 0.00 13.69 Drumright Regional Hospital 0.00 0.00 Fairview Hospital 0.00 0.00 Harper County Community Hospital 0.00 0.00 Haskell County Hospital 0.00 0.00 Holdenville General Hospital 0.00 0.00 Integris Marshall Memorial Hospital 9.73 11.43 Jane Phillips Nowata Health Center 0.00 0.00 Jefferson County Hospital 0.00 0.00 Johnston Memorial Hospital 0.00 16.16 Kingfisher Regional Hospital 0.00 0.00 Logan Medical Center 0.00 0.00 Mary Hurley Hospital 0.00 0.00 Mercy Health Love County 8.22 0.00 Okeene Municipal Hospital NA 0.00 Physicians Hospital of Anadarko NA 0.00



Prague Municipal Hospital 0.00 0.00 Quartz Mountain Medical Center NA 0.00 Rogers Mills Memorial Hospital NA 0.00 Seiling Municipal Hospital NA 0.00 St. John Sapulpa (AKA Bartlett) 0.00 0.00 Stroud Regional Medical Center 0.00 0.00 Watonga Municipal Hospital 11.64 0.00 Weatherford Regional Hospital 5.81 0.00



Hospital 2008 2009

State Rate 0.59 0.55 Bailey Medical Center 0.00 0.00 Bristow Medical Center NA 0.00 Choctaw Memorial Hospital 0.00 3.62 Craig General Hospital 1.58 0.00 Eastern Oklahoma Medical Center Inc. 0.00 0.00 Elkview General Hospital 0.00 0.00 EPIC Medical Center NA 0.00 Grady Memorial Hospital 0.00 0.00 Harmon Memorial Hospital 0.00 0.00 Hillcrest Hospital Henryetta 1.71 0.00 Hillcrest Hospital Okmulgee 0.00 0.00 Latimer County General Hospital 0.00 0.00 McBride Clinic Orthopedic Hospital, LLC 0.00 0.00 McCurtain Memorial Hospital 1.13 0.00 Memorial Hospital of Stilwell 3.90 0.00 Memorial Hospital of Texas County 0.00 0.00 Newman Memorial Hospital 0.00 0.00 Oklahoma Surgical Hospital 0.00 6.58 Okmulgee Memorial Hospital NA 0.00 Park View Hospital 5.31 0.00 Pauls Valley General Hospital 0.00 0.00



Purcell Municipal Hospital 0.00 0.00 Pushmataha Hospital 0.00 0.00 Sayre Memorial Hospital 0.00 0.00 Sequoyah Memorial Hospital 0.00 0.00 Share Memorial Hospital 0.00 0.00 St John Owasso 0.00 0.00 Tahlequah City Hospital 0.00 0.00 Wagoner Community Hospital 0.00 0.00




Claremore Regional Hospital NA 0.93 Comanche County Memorial Hospital 0.00 0.00 Community Hospital 0.00 0.00 Cushing Regional Hospital NA 1.77 Deaconess Hospital 0.34 0.00 Duncan Regional Hospital, Inc. 0.00 0.00 Edmond Regional Hospital NA 0.00 Great Plains Regional Medical Center 1.43 0.00 Hillcrest Hospital Claremore 0.87 NA Hillcrest Hospital Cushing 0.00 NA Hillcrest Hospital South 0.00 NA Hillcrest Medical Center 0.00 1.24 Integris Baptist Medical Center, Inc. 0.00 0.58 Integris Baptist Regional Health Center 0.00 0.72 Integris Bass Baptist Health Center 0.00 0.00 Integris Blackwell Regional Hospital 0.00 0.00 Integris Canadian Valley Regional Hospital 0.00 0.00 Integris Clinton Regional Hospital 5.34 0.00



Integris Grove General Hospital 2.01 0.00 Integris Mayes County Medical Center 0.00 0.00 Integris Seminole Medical Center 0.00 0.00 Integris Southwest Medical Center of OK 0.00 0.00 Jackson County Memorial Hospital 0.00 0.00 Jane Phillips Medical Center 0.00 0.00 Lakeside Women's Hospital 0.00 0.00 McAlester Regional Health Center 2.73 0.00 Medical Center of Southeastern Oklahoma 1.08 0.95 Mercy Health Center, Inc. 1.20 0.00 Mercy Memorial Health Center Inc. 1.10 0.00 Midwest Regional Medical Center 0.00 0.38 Muskogee Community Hospital NA 0.00 Muskogee Regional Medical Center 0.00 0.00 Norman Regional Hospital 0.76 1.98 Northwest Surgical Hospital 0.00 0.00 Oklahoma Center for Orthopedic & Multi Specialty Surgery 0.00 0.00 Oklahoma Heart Hospital 0.00 0.00 Oklahoma Spine Hospital, L.L.C. 0.00 0.00 OSU Medical Center 1.30 0.00 OU Medical Center 0.64 3.38 Ponca City Medical Center 4.22 0.00 Saint Francis Hospital South 0.00 0.00 Saint Francis Hospital, Inc. 0.47 0.00 SouthCrest NA 0.72 Southwestern Medical Center 0.00 0.00 St. Anthony Hospital 0.28 0.55 St. Anthony Hospital/Bone and Joint Hospital 0.00 NA St. John Medical Center, Inc. 0.93 1.37 St. Mary's Regional Medical Center 0.00 0.00 Stillwater Medical Center 0.00 0.00 Surgical Hospital of Oklahoma, L.L.C. 0.00 0.00



Tulsa Spine Hospital NA 0.00 Unity Health Center 1.52 0.00 Valley View Regional Hospital 0.00 1.52 Woodward Regional Hospital 2.06 0.00



PSI 8 Postoperative Hip Fracture

Description: Rate of discharges with an ICD-9-CM code of hip fracture in any secondary diagnosis field (not present on admission) among surgical discharges, defined by specific DRG codes and an ICD-9-CM code of major operating room procedure in any procedure field, age 18 and older. This event occurs when a patient while hospitalized as the result of a surgical procedure has fallen and which resulted in a fractured a hip. This indicator is intended to capture cases of in-hospital fracture—specifically, hip fractures. It further excludes any patients with musculoskeletal disorders and any patients with indication for trauma or cancer, or a principal diagnosis of seizure, syncope, stroke, coma, cardiac arrest, or poisoning, as these patients may have a fracture present on admission. This indicator is limited to surgical cases since previous research suggests that previously medical patients often represent conditions that are present on admission.



Drumright Regional Hospital 0.00 0.00 Haskell County Hospital 0.00 0.00 Kingfisher Regional Hospital 0.00 0.00 Logan Medical Center 0.00 0.00 Okeene Municipal Hospital 0.00 0.00 Physicians Hospital of Anadarko 0.00 0.00 St. John Sapulpa (AKA Bartlett) 0.00 0.00 Stroud Regional Medical Center 0.00 0.00 Weatherford Regional Hospital 0.00 0.00





Bailey Medical Center 0.00 0.00 Choctaw Memorial Hospital 0.00 0.00 Continuous Care Center of Tulsa 0.00 0.00 Craig General Hospital 0.00 0.00 Eastern Oklahoma Medical Center Inc. 0.00 0.00 Elkview General Hospital 0.00 0.00 Foundation Bariatric Hospital of OK, LLC 0.00 0.00 Grady Memorial Hospital 0.00 0.00 Henryetta Medical Center 0.00 0.00 Lindsay Municipal Hospital 0.00 0.00 McBride Clinic Orthopedic Hospital, LLC 0.00 0.00 McCurtain Memorial Hospital 0.00 0.00 Memorial Hospital of Stilwell 0.00 0.00 Memorial Hospital of Texas County 0.00 0.00 Newman Memorial Hospital 0.00 0.00 Oklahoma Surgical Hospital 0.00 0.00 Okmulgee Memorial Hospital 0.00 0.00 Orthopedic Hospital 0.00 0.00 Park View Hospital 0.00 0.00 Pauls Valley General Hospital 0.00 0.00 Purcell Municipal Hospital 0.00 0.00 Pushmataha Hospital 0.00 0.00 Sayre Memorial Hospital 0.00 0.00 Solara Hospital Shawnee 0.00 0.00 Solora Hospital Muskogee 0.00 0.00 St John Owasso 0.00 0.00 Tahlequah City Hospital 0.00 0.00





Bone and Joint Hospital 0.00 NA Claremore Regional Hospital 0.00 0.00 Comanche County Memorial Hospital 0.52 0.57 Community Hospital 0.00 0.00 Cushing Regional Hospital 0.00 0.00 Deaconess Hospital 0.60 0.00 Duncan Regional Hospital, Inc. 0.00 0.00 Edmond Medical Center 0.00 0.00 Edmond Specialty Hospital 0.00 0.00 Great Plains Regional Medical Center 0.00 0.00 Hillcrest Medical Center 0.00 0.79 Integris Baptist Medical Center, Inc. 0.00 0.00 Integris Baptist Regional Health Center 0.00 0.00 Integris Bass Baptist Health Center 0.00 0.00 Integris Bass Pavilion 0.00 0.00 Integris Blackwell Regional Hospital 0.00 0.00 Integris Canadian Valley Regional Hospital 0.00 0.00 Integris Clinton Regional Hospital 0.00 0.00 Integris Grove General Hospital 0.00 0.00 Integris Mayes County Medical Center 0.00 0.00 Integris Seminole Medical Center 0.00 0.00 Integris Southwest Medical Center of OK 0.00 0.00 Jackson County Memorial Hospital 0.00 0.00 Jane Phillips Medical Center 0.00 1.15 Kindred Hospital - Oklahoma City 3.17 0.00 Lakeside Women's Hospital 0.00 0.00 McAlester Regional Health Center 0.00 0.00 Medical Center of Southeastern Oklahoma 0.00 1.81 Mercy Health Center, Inc. 0.39 0.00 Mercy Memorial Health Center Inc. 0.00 0.00 Midwest Regional Medical Center 0.00 0.43 Muskogee Regional Medical Center 0.00 0.00



Norman Regional Hospital 0.00 0.00 Norman Specialty Hospital 0.00 0.00 Northwest Surgical Hospital 0.00 0.00 Oklahoma Center for Orthopedic & Multi Specialty Surgery 0.00 0.00 Oklahoma Heart Hospital 0.41 0.00 Oklahoma Spine Hospital, L.L.C. 0.00 0.00 OSU Medical Center 0.79 0.00 OU Medical Center 0.00 0.78 Ponca City Medical Center 0.00 0.00 Saint Francis Hospital at Broken Arrow 0.00 0.00 Saint Francis Hospital, Inc. 0.32 0.00 Select Specialty Hospital, Tulsa 0.00 0.00 Select Specialty Hospital-Oklahoma City 0.00 0.00 SouthCrest Hospital 0.00 0.00 Southwestern Medical Center 0.00 2.67 Southwestern Regional Medical Center 0.00 0.00 Specialty Hospital of Midwest City 0.00 0.00 St. Anthony Hospital 0.00 0.00 St. John Medical Center, Inc. 0.18 0.00 Stillwater Medical Center 0.00 0.00 Surgical Hospital of Oklahoma, L.L.C. 0.00 0.00 Unity Health Center 1.99 0.00 Valley View Regional Hospital 0.00 2.14 Woodward Regional Hospital 0.00 0.00 **Data in red are above state rate


National Healthcare Safety Network Oklahoma currently has 152 licensed hospitals with 50 of those hospitals identified as having at least one adult intensive care unit. Hospitals with adult intensive care units were required to collect and report data monthly beginning in July 2008. These hospitals were required to complete an orientation on how to utilize and enter data into the NHSN data system. Once the orientation was complete, the Infection Preventionist for the hospital initiated the enrollment process. Hospitals participating in NHSN must be a recognized healthcare entity in the United States, and be listed in or associated with a facility that is included in one of the following national databases: American Hospital Association (AHA), Centers for Medicare and Medicaid Services (CMS), or Veteran’s Affairs (VA). NHSN enables healthcare facilities to collect and use data about healthcare-associated infections,

adherence to clinical practices known to prevent healthcare-associated infections, the incidence or prevalence of multidrug-resistant organisms within their organizations, trends and coverage of healthcare personnel safety and vaccination, and adverse events related to the transfusion of blood and blood products. It is estimated that 248,000 bloodstream infections occur each year in U.S. hospitals. These infections are very serious and usually result in longer hospital stays, which result in increased cost and increased risk of morbidity and mortality. With proper management these infections can be prevented. Another common nosocomial infection in the U.S. is pneumonia. Patients who require mechanical assistance with a ventilator are at a higher risk of developing nosocomial pneumonia.

Central Line Associated Bloodstream Infection (CLABSI) The definition of a central line is an intravascular catheter that terminates at or close to the heart or in one of the great vessels such as aorta, pulmonary artery, superior vena cava, inferior vena cava, brachiocephalic veins, internal jugular veins, subclavian veins, external iliac veins, and common femoral veins. It is used for infusion, withdrawal of blood, or hemodynamic monitoring. A pacemaker wire and other non-lumenated devices inserted into central blood vessels or

the heart are not

considered central lines, because fluids are not infused, pushed, nor withdrawn through such devices.

Central line associated bloodstream infection is a laboratory confirmed primary bloodstream infection (BSI) in a patient that had a central line within the 48-hour period before the development of the BSI. There is no minimum period of time that the central line must be in place in order


for the BSI to be considered central line-associated. The data collected in NHSN are used for improving patient safety at the local and national levels. In aggregate, CDC analyzes and publishes surveillance data to estimate and characterize the national burden of healthcare-

associated infections. At the local level, the data analysis features of NHSN are available to participating facilities ranging from rate tables and graphs to statistical analysis that compares the healthcare facility’s rates with the national aggregate metrics.

Data Analyses The Standardized Infection Ratio (SIR) is calculated by dividing the number of observed infections by the number of expected infections. The number of expected infections, in the context of statistical prediction, is calculated using CLABSI rates from a standard population during a baseline time period as reported in the NHSN Report. While the CLABSI SIR can be calculated for single locations in the hospital, the measure also allows data across multiple locations, adjusting for differences in the incidence of infection among the location types. For example, you will be able to obtain one CLABSI SIR adjusting for all locations reported. Similarly, you can obtain one CLABSI SIR for all specialty care

areas in your facility. The CLABSI rate per 1000 central line days is calculated by dividing the number of CLABSI by the number of central line days and multiplying the result by 1000. The Central Line Utilization Ratio

is calculated by dividing the number of central line days by the number of patient days.

These calculations are performed separately for different types of ICUs, specialty care areas, and other locations in the institution. Separate rates and ratios will also be calculated for different types of catheters in specialty care areas and neonate intensive care units. NOTE: The SIR is calculated only if the number of expected Healthcare-Associated Infections is ≥ 1


Central Line Associated Bloodstream Infections for State This table depicts the reports of all hospitals who reported to the NHSN for the time period of January 2009 through December 2010. The time periods are recorded by six months intervals, therefore H1 would be for January through June and H2 would be from July through December. The total number of central line associated bloodstream infections for

each time period is then divided by the number of central line days, which is then multiplied by 1000 patient days. One key factor to remember is that currently the Oklahoma State Department of Health does not validate the data. The hospitals are responsible for the accuracy of the data reported into the NHSN database.

Oklahoma Central Line Associated Bloodstream Infections Summary Year Half Infection Count Number Expected Infections Number Central Line Days SIR

2009H1 64 114.33 65012 0.560

2009H2 62 113.67 65062 0.545

2010H1 82 147.33 88259 0.557

2010H2 76 144.76 86487 0.525


Central Line Associated Bloodstream Infections by Individual hospital The following charts are listed in alphabetical order and represent each facility’s infection in the intensive care units. Each facility page has a brief explanation about the facility, such as the number of licensed beds, the number of beds in the unit, and the type of patients which are admitted to the units. Data Tables Definitions: Summary Year Half: This represents the year 2009 and 2010. The label 2009H1 represents January 2009 through June 2009. The label 2009H2 represents July 2009 through December 2009. The label 2010H1 represents January 2010 through June 2010. The label 2010H2 represents July 2010 through December 2010.

Infection count: The actual infections that occurred within a facility’s intensive care units during the six month period. Number of Expected: The statistical prediction is calculated using CLABSI rates from a standard population during a baseline time period. Number of Central Line Days: The number of central lines counted in the intensive care unit at the same time each day. SIR: Standardized Infection Ratio (SIR) is the hospital’s number of infections compared to hospitals across the country as reported to the National Healthcare Safety Network. The SIR is calculated by dividing the number of observed infections by the number of expected infections.


Hospitals with Adult Intensive Care Units

Bailey Medical Center –This hospital is located in Owasso. Data was collected from an inpatient acute critical care medical surgical unit, consisting of five setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 73.

Summary Year Half Infection Count Number Expected

Number Central Line Days SIR

2009H1 0 0.116 77 .

2009H2 0 0.078 52 .

2010H1 0 0.047 31 .

2010H2 0 0.020 13 .

**(-)SIR values only calculated if number expected >= 1.

Claremore Regional Hospital – This hospital is located in Claremore. Data was collected from an inpatient acute critical care medical unit, consisting of six setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 81.



2009H1 0 0.127 67 .

2009H2 0 0.198 104 .

2010H1 0 0.137 72 .

2010H2 0 0.093 49 .



Comanche County Memorial Hospital – This hospital is located in Lawton. Data was collected from an inpatient acute critical care medical surgical unit, consisting of 20 setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 283. Summary Year Half Infection Count Number

Expected Number Central Line Days SIR

2009H1 4 2.063 1375 1.939

2009H2 5 2.700 1800 1.852

2010H1 1 3.212 2141 0.311

2010H2 4 2.828 1885 1.414

Community Hospital – This hospital is located in Oklahoma City. Data was collected from an inpatient acute critical care medical surgical unit, consisting of three setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 49.



2009H1 0 0.084 56 . 2009H2 0 0.042 28 .

2010H1 0 0.107 71 .

2010H2 0 0.033 22 . **(-)SIR values only calculated if number expected >= 1.


Cushing Regional Hospital – This hospital is located in Cushing. Data was collected from an inpatient acute critical care medical surgical unit, consisting of four setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 95.



2009H1 0 0.074 39 .

2009H2 0 0.030 16 . 2010H1 0 0.065 34 . 2010H2 0 0.044 23 . **(-)SIR values only calculated if number expected >= 1.

Deaconess Hospital – This hospital is located in Oklahoma City. Data was collected from an inpatient acute critical care medical unit, consisting of 29 setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 291.



2009H1 1 2.932 1543 0.341

2009H2 1 3.131 1648 0.319

2010H1 1 3.162 1664 0.316

2010H2 1 2.844 1497 0.352


Duncan Regional Hospital – This hospital is located in Duncan. Data was collected from an inpatient acute critical care medical surgical unit, consisting of nine setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 167.



2009H1 0 0.419 279 . 2009H2 0 0.348 232 . 2010H1 0 0.402 268 . 2010H2 0 0.483 322 . **(-)SIR values only calculated if number expected >= 1.

Eastern Oklahoma Medical Center –This hospital is located in Poteau. Data was collected from an inpatient acute critical care medical surgical unit, consisting of eight setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 84.



2009H1 0 0.716 231 .

2009H2 0 0.549 177 .

2010H1 0 0.400 129 .

2010H2 0 0.329 106 .



Grady Memorial Hospital – This hospital is located in Chickasha. Data was collected from an inpatient acute critical care medical surgical unit, consisting of seven setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 99.



2009H1 0 0.188 125 .

2009H2 0 0.331 239 .

2010H1 0 0.696 535 .

2010H2 1 0.631 507 .


Great Plains Regional Medical Center – This hospital is located in Elk City. Data was collected from an inpatient acute critical care medical unit, consisting of six setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 62.



2009H1 0 0.089 47 . 2009H2 0 0.053 28 . 2010H1 0 0.148 78 . 2010H2 0 0.110 58 .



Hillcrest Medical Center– This hospital is located in Tulsa. Data was collected from three inpatient acute critical care units, two of which were medical surgical units, and one cardiac vascular care unit. All three ICUs total 31 setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 691. Summary Year Half Infection Count Number


2009H1 3 5.634 3855 0.532

2009H2 2 5.471 3746 0.366 2010H1 0 5.139 3517 0.000 2010H2 0 4.449 3037 0.000

Integris Baptist Medical Center – This hospital is located in Oklahoma City. Data was collected from five inpatient acute critical care medical surgical units, consisting of 60 setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 640. Summary Year Half Infection Count Number


2009H1 7 10.685 7123 0.655 2009H2 3 11.646 7764 0.258 2010H1 1 11.484 7656 0.087 2010H2 1 9.455 6303 0.106


Integris Baptist Regional Health Center– This hospital is located in Miami. Data was collected from an inpatient acute critical care medical surgical unit, consisting of five setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 117.



2009H1 0 0.126 84 .

2009H2 0 0.087 58 .

2010H1 0 0.086 57 .

2010H2 0 0.143 95 .


Integris Bass Baptist Health Center – This hospital is located in Enid. Data was collected from an inpatient acute critical care medical surgical unit, consisting of seven setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 183.



2009H1 0 0.708 472 . 2009H2 0 0.891 594 . 2010H1 0 0.657 438 . 2010H2 0 0.587 391 .



Integris Canadian Valley Hospital – This hospital is located in Yukon. Data was collected from an inpatient acute critical care medical surgical unit, consisting of four setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 48.



2009H1 0 0.332 221 .

2009H2 0 0.318 212 .

2010H1 0 0.530 376 . 2010H2 0 0.568 414 . **(-)SIR values only calculated if number expected >= 1.

Integris Clinton Regional Hospital – This hospital is located in Clinton. Data was collected from an inpatient acute critical care medical surgical unit, consisting of four setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 56.



2009H1 0 0.057 38 . 2009H2 0 0.023 15 . 2010H1 0 0.056 37 . 2010H2 0 0.011 7 . **(-)SIR values only calculated if number expected >= 1.


Integris Grove General Hospital – This hospital is located in Grove. Data was collected from an inpatient acute critical care medical surgical unit, consisting of four setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 68.



2009H1 0 0.118 56 . 2009H2 0 0.101 48 . 2010H1 0 0.107 51 . 2010H2 0 0.233 111 . **(-)SIR values only calculated if number expected >= 1

Integris Southwest Medical Center – This hospital is located in Oklahoma City. Data was collected from an inpatient acute critical care medical surgical unit, consisting of 20 setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 406.



2009H1 0 2.160 1440 0.000

2009H2 1 2.906 1937 0.344

2010H1 1 2.982 1988 0.335

2010H2 3 2.752 1879 1.090


Jackson County Memorial Hospital – This hospital is located in Altus. Data was collected from an inpatient acute critical care medical surgical unit, consisting of 12 setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 99.




Jane Phillips Medical Center – This hospital is located in Bartlesville. Data was collected from an inpatient acute critical care medical surgical unit, consisting of eight setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 137.




.


McAlester Regional Health Center – This hospital is located in McAlester. Data was collected from an inpatient acute critical care medical surgical unit, consisting of 14 setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 171.




McCurtain Memorial Hospital – This hospital is located in Idabel. Data was collected from an inpatient acute critical care medical surgical unit, consisting of six setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 106.





Medical Center of Southeastern Oklahoma – This hospital is located in Durant. Data was collected from an inpatient acute critical care medical surgical unit, consisting of eight setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 148.




Memorial Hospital of Texas County – This hospital is located in Guymon. Data was collected from an inpatient acute critical care medical surgical unit, consisting of four setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 47.



2009H2 0 0.011 7 .

2010H1 0 0.005 3 .

2010H2 0 0.003 2 . **(-)SIR values only calculated if number expected >= 1 2009H1 Data missing


Mercy Health Center – This hospital is located in Oklahoma City. Data was collected from an inpatient acute critical care medical surgical unit, consisting of 36 adult setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 393.



2009H1 6 4.653 3102 1.289 2009H2 3 4.010 2673 0.748

2010H1 1 4.538 3025 0.220 2010H2 2 5.394 3596 0.371

Mercy Memorial Health Center – This hospital is located in Ardmore. Data was collected from an inpatient acute critical care medical surgical unit, consisting of 13 setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 190.





Midwest Regional Medical Center – This hospital is located in Midwest City. Data was collected from an inpatient acute critical care medical surgical unit, consisting of 24 setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 255. Summary Year Half Infection Count Number


2009H1 2 5.807 2749 0.344 2009H2 3 5.296 2513 0.566 2010H1 2 3.408 1647 0.587 2010H2 1 3.330 1624 0.300

Muskogee Regional Medical Center – This hospital is located in Muskogee. Data was collected from an inpatient acute critical care medical surgical unit, consisting of 24 setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 275. Summary Year Half Infection Count Number


2009H1 0 1.511 1007 0.000 2009H2 0 0.716 477 . 2010H1 0 1.208 805 0.000 2010H2 0 0.552 368 . **(-)SIR values only calculated if number expected >= 1


Newman Memorial Hospital – This hospital is located in Shattuck. Data was collected from an inpatient acute critical care medical surgical unit, consisting of two setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 79.




Norman Regional Hospital – This hospital is located in Norman. Data was collected from an inpatient acute critical care medical surgical unit, consisting of 43 setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 518.



2009H1 1 5.364 3304 0.186

2009H2 0 5.275 3232 0.000

2010H1 1 5.142 3176 0.194

2010H2 2 4.921 2971 0.406


Oklahoma Heart Hospital – This hospital is located in Oklahoma City. Data was collected from an inpatient acute critical care medical surgical unit, consisting of 16 setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 99. Summary Year Half Infection Count Number


2009H1 2 3.300 2200 0.606 2009H2 2 3.612 2408 0.554 2010H1 1 3.528 2352 0.283 2010H2 1 3.519 2346 0.284

Oklahoma Heart Hospital South – This hospital is located in Oklahoma City. This hospital has only been open since January, 2010. Data was collected from an inpatient acute critical care medical surgical unit, consisting of 12 setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 46.

**(-)SIR values only calculated if number expected >= 1



2010H1 0 0.795 530 .

2010H2 0 1.329 886 0.000


Oklahoma State University Medical Center – This hospital is located in Tulsa. Data was collected from an inpatient acute critical care medical surgical unit, consisting of 54 setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 249. Summary Year Half Infection Count Number


2009H1 0 5.550 2643 0.000 2009H2 4 3.692 1758 1.083

2010H1 1 4.668 2223 0.214

2010H2 3 4.679 2228 0.641

OU Medical Center

OU Medical Center – This hospital is located in Oklahoma City. Data was collected from two inpatient acute critical care units, two of which were Medical Surgical Units, and one Trauma Critical Care Unit. All three ICUs total 151 setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 689. Summary Year Half Infection Count Number


2009H1 12 16.125 6145 0.744 2009H2 9 15.619 6015 0.576 2010H1 5 15.719 6125 0.318 2010H2 1 16.093 6124 0.062 OU Medical Center – Edmond This unit is located in Edmond. Data was collected from an inpatient acute critical care medical surgical unit, consisting of 12 setup and staffed beds. This facility is a unit of the OU Medical Center. Summary Year Half Infection Count Number


2009H1 0 0.533 355 . 2009H2 2 1.161 774 1.723 2010H1 2 1.158 772 1.727 2010H2 0 1.419 946 0.000 **(-)SIR values only calculated if number expected >= 1


Pauls Valley General Hospital – This hospital is located in Pauls Valley. Data was collected from an inpatient acute critical care medical surgical unit, consisting of three setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 64.



2009H1 0 0.012 8 .

2009H2 0 0.015 10 . **(-)SIR values only calculated if number expected >= 1 2010 Data missing

Ponca City Medical Center – This hospital is located in Ponca City. Data was collected from an inpatient acute critical care medical unit, consisting of ten setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 140.





Southwestern Medical Center – This hospital is located in Lawton. Data was collected from an inpatient acute critical care medical surgical unit, consisting of nine setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 199.




Southwestern Regional Medical Center– (Cancer Treatment Center of America)-This hospital is located in Tulsa. Data was collected from an inpatient acute critical care medical surgical unit, consisting of seven setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 43. Summary Year Half Infection Count Number


2009H1 2 1.109 739 1.803 2009H2 2 1.131 754 1.768 2010H1 0 1.040 693 0.000 2010H2 2 1.028 685 1.946


St. Anthony Hospital – This hospital is located in Oklahoma City. Data was collected from two inpatient acute critical care medical surgical units, consisting of 29 setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 686. Summary Year Half Infection Count Number


2009H1 8 4.395 2930 1.820 2009H2 6 3.924 2616 1.529 2010H1 10 5.222 3481 1.915 2010H2 2 4.409 2939 0.454

Saint Francis Hospital – This hospital is located in Tulsa. Data was collected from three inpatient acute critical care units, medical surgical critical care, cardiac critical care, and trauma critical care. All three ICUs total to 139 setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 928. Summary Year Half Infection Count Number


2009H1 12 22.297 12454 0.538 2009H2 8 21.453 11900 0.373 2010H1 16 21.309 11994 0.751 2010H2 20 22.828 12948 0.876


St. John Medical Center – This hospital is located in Tulsa. Data was collected from an inpatient acute critical care medical surgical unit, consisting of 105 setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 703. Summary Year Half Infection Count Number


2009H1 3 8.670 4754 0.346

2009H2 5 9.655 5234 0.518 2010H1 11 12.240 6622 0.899

2010H2 8 12.307 6688 0.650

St. Mary’s Regional Medical Center – This hospital is located in Enid. Data was collected from an inpatient acute critical care medical surgical unit, consisting of 11 setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 245. Summary Year Half Infection Count Number


2009H1 0 0.917 611 .

2009H2 0 1.218 812 0.000 2010H1 2 1.277 851 1.566 2010H2 2 1.061 707 1.885 **(-)SIR values only calculated if number expected >= 1


Saint Francis Hospital South – This hospital is located in Tulsa. Data was collected from an inpatient acute critical care medical unit, consisting of 12 setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 96.




Stillwater Medical Center – This hospital is located in Stillwater. Data was collected from an inpatient acute critical care medical surgical unit, consisting of seven setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 119.





Tahlequah City Hospital – This hospital is located in Tahlequah. Data was collected from an inpatient acute critical care medical surgical unit, consisting of 14 setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 100.



2009H1 0 0.921 575 .

2009H2 4 0.948 580 .

2010H1 1 0.974 576 .

2010H2 0 0.839 501 .

**(-)SIR values only calculated if number expected >= 1

Unity Health Center – This hospital is located in Shawnee. Data was collected from an inpatient acute critical care medical surgical unit, consisting of 14 setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 114.



2009H1 0 0.455 303 .

2009H2 1 0.201 134 .

2010H1 2 0.291 194 .

2010H2 0 0.176 117 . **(-)SIR values only calculated if number expected >= 1


Valley View Regional Hospital – This hospital is located in Ada. Data was collected from an inpatient acute critical care medical surgical unit, consisting of 12 setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 156.




Wagoner Community Hospital- This hospital is located in Wagoner. Data was collected from an inpatient acute critical care medical surgical unit, consisting of six setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 100.



2009H2 0 0.004 2 .

2010H1 0 0.011 6 .

2010H2 0 0.063 33 .

**(-)SIR values only calculated if number expected >=


Woodward Hospital – This hospital is located in Woodward. Data was collected from an inpatient acute critical care medical surgical unit, consisting of six setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 87.





Ventilator-Associated Pneumonia (VAP) Events In 2002, an estimated 250,000 healthcare-associated pneumonias developed in U.S. hospitals and 36,000 of these were associated with deaths. Patients with mechanically assisted ventilation have a high risk of developing healthcare-associated pneumonia. According to the Centers for Disease Control and Prevention, for the year 2010, NHSN facilities reported more than 3525 VAPs and incidence for various types of hospital units ranged from 0.0-5.8 events per 1,000 ventilator days on the average.

The definition for VAP events excludes infections associated with complications or extensions of infections already present on admission, unless a change in pathogen or symptoms strongly suggest the acquisition of a new infection area not considered healthcare-associated. Therefore, infections that become apparent within the first few days of admission must be carefully reviewed to determine whether they should be considered healthcare-associated. There is no minimum period of time that the ventilator must be in place in order for the pneumonia to be considered ventilator-associated. A ventilator is a device to assist or control respiration continuously, inclusive of the weaning period, through a tracheotomy or by endo-tracheal intubation. Healthcare-associated pneumonia can be characterized by its onset: early or late. Early onset pneumonia

occurs during the first four days of hospitalization and is often caused by Moraxella catarrhalis, Haemophi-lus influenza, or Streptococcus pneumonia. Causative agents of late onset pneumonia are frequently gram-negative bacilli or Staphylo-coccus aureus, including methicil-lin-resistant Staphylococcus

aureus. Viruses (e.g., Influenza A and B or Respiratory Syncytial Virus) can cause early and late onset healthcare-associated pneumonia, whereas yeasts, fungi, legionellae, and Pneumocystis carinii are usually pathogens of late onset pneumonia.


The tables below depict the reports of all hospitals who reported to NHSN for the time period from January through December 2009 and 2010. The VAP rate per 1000 ventilator days is calculated by

dividing the number of VAPs by the number of ventilator days and multiplying the result by 1000. The definitions and additional information may be found at the NHSN CDC website www.cdc.gov/nhsn.

Ventilator Associated Pneumonias Listed by Individual Hospital The following tables are listed in alphabetical order and represent each facility’s infection rate by intensive care units. If the facility has more than one unit the numbers will be listed by the identifier the infection control preventionist has labeled the individual unit in the NHSN database. Each facility page has a brief explanation about the facility such as the number of licensed beds, the number of beds in the unit, and the type of patients which are admitted to the units. Data table definitions: Summary Year: This represents the years 2009 and 2010. Months: This is the number of months that data were collected and entered into NHSN. VAP Count: Actual number of infections that occurred during a

month on a particular intensive care unit. Number of Ventilator Days: For each day of the month, at the same time each day, the number of patients on the selected unit who are on a ventilator were recorded. These numbers are summed at the end of the month. VAP Rate: The number of Ventilator-Associated Pneumonia infections divided by the number of ventilator days multiplied by 1000. Number of Patient Days: For each day of the month, at the same time each day, the number of patients on the selected unit was recorded. These numbers were summed at the end of the month. .


Hospitals with Adult Intensive Care Units Bailey Medical Center – This hospital is located in Owasso. Data were collected from an inpatient acute critical care medical surgical unit, consisting of five setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 73. Summary Year Months VAP Count Number Ventilator Days VAP Rate Number Patient Days

2009 12 0 59 0.000 287

2010 12 0 26 0.000 197

Claremore Regional Hospital – This hospital is located in Claremore. Data were collected from an inpatient acute critical care medical unit, consisting of six setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 81. Summary Year Months VAP Count Number Ventilator Days VAP Rate Number Patient Days

2009 12 0 73 0.000 1394

2010 12 0 101 0.000 5485

Comanche County Memorial Hospital – This hospital is located in Lawton. Data were collected from an inpatient acute critical care medical surgical unit, consisting of 20 setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 283. Summary Year Months VAP Count Number Ventilator Days VAP Rate Number Patient Days

2009 12 10 3580 2.793 5764

2010 12 10 3637 2.750 5430


Community Hospital – This hospital is located in Oklahoma City. Data were collected from an inpatient acute critical care medical surgical unit, consisting of three setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 49. Summary Year Months VAP Count Number Ventilator Days VAP Rate Number Patient Days

2009 12 0 22 0.000 160 2010 12 1 25 40.000 150

Cushing Regional Hospital – This hospital is located in Cushing. Data were collected from an inpatient acute critical care medical surgical unit, consisting of four setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 95. Summary Year Months VAP Count Number Ventilator Days VAP Rate Number Patient Days

2009 11 0 55 0.000 394

2010 12 0 33 0.000 440

Deaconess Hospital – This hospital is located in Oklahoma City. Data were collected from an inpatient acute critical care medical unit, consisting of 29 setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 291. Summary Year Months VAP Count Number Ventilator Days VAP Rate Number Patient Days

2009 12 0 2541 0.000 4378

2010 12 1 2365 0.423 4366


Duncan Regional Hospital – This hospital is located in Duncan. Data were collected from an inpatient acute critical care medical surgical unit, consisting of nine setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 167. Summary Year Months VAP Count Number Ventilator Days VAP Rate Number Patient Days

2009 12 0 251 0.000 1634

2010 12 0 307 0.000 1804

Eastern Oklahoma Medical Center – This hospital is located in Poteau. Data were collected from an inpatient acute critical care medical surgical unit, consisting of eight setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 84. Summary Year Months VAP Count Number Ventilator Days VAP Rate Number Patient Days

2009 12 0 134 0.000 1828

2010 12 0 80 0.000 1626

Grady Memorial Hospital – This hospital is located in Chickasha. Data were collected from an inpatient acute critical care medical surgical unit, consisting of seven setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 99.

Summary Year Months VAP Count Number Ventilator Days VAP Rate Number Patient Days

2009 11 0 43 0.000 1303

2010 12 1 46 21.739 1116


Great Plains Regional Medical Center – This hospital is located in Elk City. Data were collected from an inpatient acute critical care medical unit, consisting of six setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 62. Summary Year Months VAP Count Number Ventilator Days VAP Rate Number Patient Days

2009 12 0 79 0.000 2506 2010 12 0 116 0.000 1383

Hillcrest Medical Center – This hospital is located in Tulsa. Data were collected from three inpatient acute critical care units, two of which were Medical Surgical Units, and one Cardiac Vascular Care Unit. All three ICUs total 31 setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 691. Summary Year Months VAP Count Number Ventilator Days VAP Rate Number Patient Days

Unit A 2009 12 2 1452 1.377 4158 Unit A 2010 12 0 1439 0.000 4076

Unit B 2009 12 0 721 0.000 1702

Unit B 2010 12 0 669 0.000 2001

Integris Baptist Medical Center – This hospital is located in Oklahoma City. Data were collected from five inpatient acute critical care medical surgical units, consisting of 60 setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 640. Summary Year Months VAP Count Number Ventilator Days VAP Rate Number Patient Days

Unit A 2009 12 1 2010 0.498 3624 Unit A 2010 12 1 1972 0.507 3427 Unit B 2009 12 2 1831 1.092 3760 Unit B 2010 12 0 1527 0.000 3507 Unit C 2009 12 1 1865 0.536 3559 Unit C 2010 12 2 1707 1.172 3309 Unit D 2009 12 2 2206 0.907 3307 Unit D 2010 12 0 1917 0.000 3025 Unit E 2009 12 2 1960 1.020 3428 Unit E 2010 12 0 1849 0.000 3213


Integris Baptist Regional Hospital – This hospital is located in Miami. Data were collected from an inpatient acute critical care medical surgical unit, consisting of five setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 117. Summary Year Months VAP Count Number Ventilator Days VAP Rate Number Patient Days

2009 12 0 91 0.000 1021 2010 12 0 100 0.000 1148

Integris Bass Baptist Health Center – This hospital is located in Enid. Data were collected from an inpatient acute critical care medical surgical unit, consisting of seven setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 183. Summary Year Months VAP Count Number Ventilator Days VAP Rate Number Patient Days

2009 12 2 823 2.430 1417

2010 12 0 794 0.000 1466

Integris Canadian Valley Hospital – This hospital is located in Yukon. Data were collected from an inpatient acute critical care medical surgical unit, consisting of four setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 48. Summary Year Months VAP Count Number Ventilator Days VAP Rate Number Patient Days

2009 12 0 176 0.000 1243 2010 12 0 228 0.000 1802


Integris Clinton Regional Hospital – This hospital is located in Clinton. Data were collected from an inpatient acute critical care medical surgical unit, consisting of four setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 56. Summary Year Months VAP Count Number Ventilator Days VAP Rate Number Patient Days

2009 12 0 70 0.000 356

2010 10 0 70 0.000 231

Integris Grove General Hospital –This hospital is located in Grove. Data were collected from an inpatient acute critical care medical surgical unit, consisting of four setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 68. Summary Year Months VAP Count Number Ventilator Days VAP Rate Number Patient Days

2009 12 0 93 0.000 594

2010 12 0 89 0.000 802

Integris Southwest Medical Center –This hospital is located in Oklahoma City. Data were collected from an inpatient acute critical care medical surgical unit, consisting of 20 setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 406. Summary Year Months VAP Count Number Ventilator Days VAP Rate Number patient Days

2009 12 3 3382 0.887 5922

2010 11 1 2973 0.336 5199


Jackson County Memorial Hospital – This hospital is located in Altus. Data were collected from an inpatient acute critical care medical surgical unit, consisting of 12 setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 99. Summary Year Months VAP Count Number Ventilator Days VAP Rate Number Patient Days

2009 12 0 201 0.000 1135

2010 12 2 379 5.277 1293

Jane Phillips Medical Center – This hospital is located in Bartlesville. Data were collected from an inpatient acute critical care medical surgical unit, consisting of eight setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 137. Summary Year Months VAP Count Number Ventilator Days VAP Rate Number Patient Days

2009 12 2 405 4.938 1732 2010 12 1 441 2.268 1774

McAlester Regional Health Center – This hospital is located in McAlester. Data were collected from an inpatient acute critical care medical surgical unit, consisting of 14 setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 171. Summary Year Months VAP Count Number Ventilator Days VAP Rate Number Patient Days

2009 11 0 276 0.000 2040

2010 8 0 220 0.000 4938


McCurtain Memorial Hospital – This hospital is located in Idabel. Data were collected from an inpatient acute critical care medical surgical unit, consisting of six setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 106. Summary Year Months VAP Count Number Ventilator Days VAP Rate Number Patient Days

2009 12 0 52 0.000 666 2010 12 0 38 0.000 710

Medical Center of Southeastern Oklahoma – This hospital is located in Durant. Data were collected from an inpatient acute critical care medical surgical unit, consisting of eight setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 148. Summary Year Months VAP Count Number Ventilator Days VAP Rate Number Patient Days

2009 12 0 263 0.000 1787

2010 12 0 245 0.000 1718

Memorial Hospital of Texas County – This hospital is located in Guymon. Data were collected from an inpatient acute critical care medical surgical unit, consisting of four setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 47. Summary Year Months VAP Count Number Ventilator Days VAP Rate Number Patient

Days 2009 12 0 5 0.000 14

2010 12 0 20 0.000 32


Mercy Health Center – This hospital is located in Oklahoma City. Data were collected from an inpatient acute critical care medical surgical unit, consisting of 36 adult setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 393. Summary Year Months VAP Count Number Ventilator Days VAP Rate Number Patient Days

2009 12 0 2749 0.000 9474 2010 12 4 2940 1.361 9502

Mercy Memorial Health Center – This hospital is located in Ardmore. Data were collected from an inpatient acute critical care medical surgical unit, consisting of 13 setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 190. Summary Year Months VAP Count Number Ventilator Days VAP Rate Number Patient Days

2009 12 1 1186 0.843 2896

2010 12 2 1040 1.923 2697

Midwest Regional Medical Center – This hospital is located in Midwest City. Data were collected from an inpatient acute critical care medical surgical unit, consisting of 24 setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 255. Summary Year Months VAP Count Number Ventilator Days VAP Rate Number Patient Days

2009 12 3 834 3.597 3266

2010 12 3 856 3.505 3726


Muskogee Regional Medical Center – This hospital is located in Muskogee. Data were collected from an inpatient acute critical care medical surgical unit, consisting of 24 setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 275. Summary Year Months VAP Count Number Ventilator Days VAP Rate Number Patient Days

2009 12 1 4277 0.234 7785 2010 12 8 3394 2.357 10837

Newman Memorial Hospital – This hospital is located in Shattuck. Data were collected from an inpatient acute critical care medical surgical unit, consisting of two setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 79. Summary Year Months VAP Count Number Ventilator Days VAP Rate Number Patient Days

2009 12 0 1 0.000 2515

2010 12 0 20 0.000 2142

Norman Regional Hospital – This hospital is located in Norman. Data were collected from an inpatient acute critical care medical surgical unit, consisting of 43 setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 518. Summary Year Months VAP Count Number Ventilator Days VAP Rate Number Patient Days

2009 12 3 2139 1.403 5896 2010 12 2 2391 0.836 5527


Oklahoma Heart Hospital – This hospital is located in Oklahoma City. Data were collected from an inpatient acute critical care medical surgical unit, consisting of 16 setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 99. Summary Year Months VAP Count Number Ventilator Days VAP Rate Number Patient Days

2009 11 6 2727 2.200 5005 2010 12 4 2651 1.509 5388

Oklahoma Heart Hospital South – This hospital is located in Oklahoma City. Data were collected from an inpatient acute critical care medical surgical unit, consisting of 12 setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 46. Summary Year Months VAP Count Number Ventilator Days VAP Rate Number Patient Days

2010 10 0 717 0.000 3399

Oklahoma State University Medical Center – This hospital is located in Tulsa. Data were collected from an inpatient acute critical care medical surgical unit, consisting of 54 setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 249. Summary Year Months VAP Count Number Ventilator Days VAP Rate Number Patient Days

2009 11 5 2301 2.173 6286

2010 12 7 2110 3.318 5571


OU Medical Center – This hospital is located in Oklahoma City with a unit in Edmond. Data were collected from two inpatient acute critical care units, two of which were medical surgical units, and one trauma critical care unit. In 2009 there were five units with a total of 151 setup and staffed beds, and in 2010 there were five units with a total of 182 setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 689. location Summary

Year Months VAP

Count Number Ventilator

Days VAP Rate

Number Patient Days

ICU-A 2009 2 1 179 5.587 332 ICU-A 2010 12 3 886 3.386 1882 ICU-B 2009 12 12 2310 5.195 5526 ICU-B 2010 12 12 2489 4.821 5511 ICU-C 2009 12 10 3565 2.805 6261 ICU-C 2010 12 9 3267 2.755 6222 ICU-D 2009 12 30 3733 8.036 5298 ICU-D 2010 12 28 3720 7.527 5331 Edmond 2009 6 0 160 0.000 1351 Edmond 2010 12 0 328 0.000 2896

Pauls Valley General Hospital –This hospital is located in Pauls Valley. Data were collected from an inpatient acute critical care medical surgical unit, consisting of three setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 64. Summary Year Months VAP Count Number Ventilator Days VAP Rate Number Patient Days

2010 1 0 0 . 1


Ponca City Medical Center – This hospital is located in Ponca City. Data were collected from an inpatient acute critical care medical unit, consisting of ten setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 140. Summary Year Months VAP Count Number Ventilator Days VAP Rate Number Patient Days

2009 7 0 64 0.000 1049

2010 12 0 186 0.000 1767

Southwestern Medical Center – This hospital is located in Lawton. Data were collected from an inpatient acute critical care medical surgical unit, consisting of 9 setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 199. Summary Year Months VAP Count Number Ventilator Days VAP Rate Number Patient Days

2009 12 0 263 0.000 1787

2010 12 0 245 0.000 1718

Southwestern Regional Medical Center–(Cancer Treatment Center of America) -This hospital is located in Tulsa. Data were collected from an inpatient acute critical care medical surgical unit, consisting of seven setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 43. Summary Year Months VAP Count Number Ventilator Days VAP Rate Number Patient Days

2009 12 0 157 0.000 1891

2010 12 1 146 6.849 1647


St. Anthony Hospital – This hospital is located in Oklahoma City. Data were collected from two inpatient acute critical care medical surgical units, consisting of 29 setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 686. Location Summary

Year Months VAP


Days VAP Rate

Number Patient Days

ICU A 2009 12 0 1584 0.000 4428 ICU A 2010 12 0 1726 0.000 4409 ICU B 2009 12 1 1643 0.609 5282 ICU B 2010 12 1 1913 0.523 4881

Saint Francis Hospital Saint Francis Hospital – This hospital is located in Tulsa. Data were collected from three inpatient acute critical care units, medical surgical critical care, cardiac critical care, and trauma critical care. All three ICUs total to 139 setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 928. Location Summary

Year Months VAP


Days VAP Rate

Number Patient Days

ICU A 2009 12 3 2425 1.237 5532 ICU A 2010 12 1 2137 0.468 5427 ICU B 2009 12 6 4672 1.284 9880 ICU B 2010 12 0 2732 0.000 6295 ICU C 2009 2 0 375 0.000 923 ICU C 2010 12 2 2538 0.788 5547 ICU D 2009 12 2 2447 0.817 4552 ICU D 2010 12 4 2214 1.807 4383 ICU E 2009 12 7 3297 2.123 5522 ICU E 2010 12 17 3673 4.628 6015


St. John Medical Center – This hospital is located in Tulsa. Data were collected from an inpatient acute critical care medical surgical unit, consisting of 105 setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 703. Location Summary Year Months VAP Count Number

Ventilator Days VAP Rate Number

Patient Days

ICU A 2009 7 2 1917 1.043 3986 ICU A 2010 12 11 2791 3.941 6828 ICU B 2009 12 17 2897 5.868 5311 ICU B 2010 12 43 2865 15.009 6450 ICU C 2009 12 7 1566 4.470 3932 ICU C 2010 12 6 1471 4.079 4179

St. Mary’s Regional Medical Center – This hospital is located in Enid. Data were collected from an inpatient acute critical care medical surgical unit, consisting of 11 setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 245. Summary Year Months VAP Count Number Ventilator Days VAP Rate Number Patient Days

2009 12 1 935 1.070 2303 2010 12 0 1075 0.000 2420

Saint Francis Hospital South – This hospital is located in Tulsa. Data were collected from an inpatient acute critical care medical unit, consisting of 12 setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 96. Summary Year Months VAP Count Number Ventilator Days VAP Rate Number Patient Days

2009 12 0 134 0.000 698 2010 12 0 137 0.000 821


Stillwater Medical Center – This hospital is located in Stillwater. Data were collected from an inpatient acute critical care medical surgical unit, consisting of seven setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 119. Summary Year Months VAP Count Number Ventilator Days VAP Rate Number Patient Days

2009 12 0 275 0.000 1079

2010 12 0 127 0.000 1196

Tahlequah City Hospital – This hospital is located in Tahlequah. Data were collected from an inpatient acute critical care medical surgical unit, consisting of 14 setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 100. Location Summary Year Months VAP Count Number Ventilator Days VAP Rate Number

Patient Days ICU A 2009 10 0 177 0.000 1407 ICU A 2010 12 1 135 7.407 1692 ICU B 2009 12 5 257 19.455 1967 ICU B 2010 12 2 205 9.756 1908

Unity Health Center – This hospital is located in Shawnee. Data were collected from an inpatient acute critical care medical surgical unit, consisting of 14 setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 114. Summary Year Months VAP Count Number Ventilator Days VAP Rate Number Patient Days

2009 12 0 536 0.000 2438

2010 12 0 412 0.000 2272


Valley View Regional Hospital – This hospital is located in Ada. Data was collected from an inpatient acute critical care medical surgical unit, consisting of 12 setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 156. Summary Year Months VAP Count Number Ventilator Days VAP Rate Number Patient Days

2009 12 1 434 2.304 1559

2010 12 0 287 0.000 1547

Woodward Hospital – This hospital is located in Woodward. Data was collected from an inpatient acute critical care medical surgical unit, consisting of six setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 87. Summary Year Months VAP Count Number Ventilator Days VAP Rate Number Patient Days

2009 12 0 98 0.000 260

2010 12 0 137 0.000 871

Wagoner Hospital – This hospital is located in Wagoner. Data was collected from an inpatient acute critical care medical surgical unit, consisting of six setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 100. Summary Year Months VAP Count Number Ventilator Days VAP Rate Number Patient Days

2009 4 0 2 0.000 157 2010 12 0 5 0.000 398


Hospital Compare

www.hospitalcompare.hhs.gov The Centers for Medicare & Medicaid Services (CMS), the Hospital Quality Alliance (HQA) and the nation's hospitals are working together to create and publicly report hospital quality information as related to care. This information measures how well hospitals care for their patients, and whether the care was paid for by Medicare, Medicaid, or a private health insurance plan. The hospital quality measures on the Hospital Compare website show recommended treatments for some of the most common and costly conditions that hospitals treat. Research has shown that these clinical practice treatments provide the best results for most patients with those conditions and are an important part of the patients' overall care.

Hospitals, doctors, scientists, and other healthcare professionals agree that these quality measures give a good snapshot of the quality of care that hospitals give to patients. Hospitals should try to give all of their patients this recommended care when it is appropriate. The goal for each measure is 100 percent, which hospitals should strive to achieve. However, when making informed decisions you should know that a hospital's quality is more than just its scores on these measures. A hospital should be able to tell the public what steps it is taking to improve its care. The information you will find on the Hospital Compare website is intended to help you when you talk with your physician or hospital about how you can best get the care you need.

Patients and Their Families

If you are a patient or someone helping a patient with his or her healthcare decisions, you can use the information on the Hospital Compare website to do the following:

1. Talk to your healthcare provider and local hospital staff about what this information means and how it

can be used to make healthcare decisions.

2. View information on other websites about hospital quality.

3. Review the performance of hospitals in your state.

4. Gather other information about hospitals.


References: Y. Vonnie Meritt, MPH, R.N. Director of Quality Initiatives Oklahoma State Department of Health 1000 NE 10Room 1113

th

Oklahoma City, OK 73117 405-271-6576 Email: [email protected] Oklahoma State Department of Health 1000 NE 10th

Oklahoma City, OK 73117-1299

405-271-5600 http://www.health.ok.gov Oklahoma Foundation for Medical Quality 14000 Quail Springs Parkway Suite 400 Oklahoma City, OK 73134 405-840-2891 http://www.ofmq.com Oklahoma Hospital Association 4000 N. Lincoln Blvd. Oklahoma City, OK 73105 405-427-9537 http://www.okoha.com Oklahoma Healthcare Authority 4545 N. Lincoln Blvd. Suite 124 Oklahoma City, OK 73105 405-552-7300 http://www.ohca.state.ok.us/ Board of Medical Licensure and Supervision 5104 N. Francis, Suite C Oklahoma City, OK 73118-6020 405-848-6841 http://www.okmedicalboard.org

mailto:[email protected]�

http://www.health.ok.gov/�

http://www.ofmq.com/�

http://www.okoha.com/�

http://www.ohca.state.ok.us/�

http://www.okmedicalboard.org/�


State Board of Osteopathic Examiners 4848 N. Lincoln Blvd, No 100 Oklahoma City, OK 73105-3335 405-528-8625 http://www.ok.gov/osboe Oklahoma Board of Nursing 2915 N. Classen Blvd, Suite 524 Oklahoma city, OK 73106 405-962-1800 http://www.ok.gov/nursing State Pharmacy Board 4545 N. Lincoln Blvd, Suite 112 Oklahoma city, OK 73105-3488 405-521-3815

http://www.ok.gov/OSBP

http://www.hospitalcompare.hhs.gov http://www.qualityindicators.ahrq.gov/index.htm http://www.qualityindicators.ahrq.gov/psi_overview.htm http://www.cdc.gov/nhsn/

http://www.ok.gov/osboe�

http://www.ok.gov/nursing�

http://www.hospitalcompare.hhs.gov/�

http://www.qualityindicators.ahrq.gov/index.htm�

http://www.qualityindicators.ahrq.gov/psi_overview.htm�

Chairman - Oklahoma Hospital Annual... · 31/10/2012 · The Oklahoma Hospital Annual Report 2011...

Documents

Transcript of Chairman - Oklahoma Hospital Annual... · 31/10/2012 · The Oklahoma Hospital Annual Report 2011...